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Gwilym BL, Pallmann P, Waldron CA, Thomas-Jones E, Milosevic S, Brookes-Howell L, Harris D, Massey I, Burton J, Stewart P, Samuel K, Jones S, Cox D, Clothier A, Edwards A, Twine CP, Bosanquet DC, Benson R, Birmpili P, Blair R, Bosanquet DC, Dattani N, Dovell G, Forsythe R, Gwilym BL, Hitchman L, Machin M, Nandhra S, Onida S, Preece R, Saratzis A, Shalhoub J, Singh A, Forget P, Gannon M, Celnik A, Duguid M, Campbell A, Duncan K, Renwick B, Moore J, Maresch M, Kamal D, Kabis M, Hatem M, Juszczak M, Dattani N, Travers H, Shalan A, Elsabbagh M, Rocha-Neves J, Pereira-Neves A, Teixeira J, Lyons O, Lim E, Hamdulay K, Makar R, Zaki S, Francis CT, Azer A, Ghatwary-Tantawy T, Elsayed K, Mittapalli D, Melvin R, Barakat H, Taylor J, Veal S, Hamid HKS, Baili E, Kastrisios G, Maltezos C, Maltezos K, Anastasiadou C, Pachi A, Skotsimara A, Saratzis A, Vijaynagar B, Lau S, Velineni R, Bright E, Montague-Johnstone E, Stewart K, King W, Karkos C, Mitka M, Papadimitriou C, Smith G, Chan E, Shalhoub J, Machin M, Agbeko AE, Amoako J, Vijay A, Roditis K, Papaioannou V, Antoniou A, Tsiantoula P, Bessias N, Papas T, Dovell G, Goodchild F, Nandhra S, Rammell J, Dawkins C, Lapolla P, Sapienza P, Brachini G, Mingoli A, Hussey K, Meldrum A, Dearie L, Nair M, Duncan A, Webb B, Klimach S, Hardy T, Guest F, Hopkins L, Contractor U, Clothier A, McBride O, Hallatt M, Forsythe R, Pang D, Tan LE, Altaf N, Wong J, Thurston B, Ash O, Popplewell M, Grewal A, Jones S, Wardle B, Twine C, Ambler G, Condie N, Lam K, Heigberg-Gibbons F, Saha P, Hayes T, Patel S, Black S, Musajee M, Choudhry A, Hammond E, Costanza M, Shaw P, Feghali A, Chawla A, Surowiec S, Encalada RZ, Benson R, Cadwallader C, Clayton P, Van Herzeele I, Geenens M, Vermeir L, Moreels N, Geers S, Jawien A, Arentewicz T, Kontopodis N, Lioudaki S, Tavlas E, Nyktari V, Oberhuber A, Ibrahim A, Neu J, Nierhoff T, Moulakakis K, Kakkos S, Nikolakopoulos K, Papadoulas S, D'Oria M, Lepidi S, Lowry D, Ooi S, Patterson B, Williams S, Elrefaey GH, Gaba KA, Williams GF, Rodriguez DU, Khashram M, Gormley S, Hart O, Suthers E, French S. Short-term risk prediction after major lower limb amputation: PERCEIVE study. Br J Surg 2022; 109:1300-1311. [PMID: 36065602 DOI: 10.1093/bjs/znac309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/06/2022] [Accepted: 07/31/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery. METHODS The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance. RESULTS Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679). CONCLUSION Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.
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Ibrahim A, Murtaja A, Oberhuber A. Indocyanine Green to Visualize and Resect Pulmonary Sequestration in Adults. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03564-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AbstractPulmonary sequestration (PS) is a rare congenital pulmonary dysplasia which presents with recurrent chest infections and haemoptysis. Its diagnosis is difficult and suspected on contrast-enhanced chest CT. The definitive treatment of pulmonary sequestration is surgical resection or endoluminal occlusion of the abnormal feeding vessel. Here, we report an innovative technique in which per-operative indocyanine green guided excision of intra-lobar sequestrated lung parenchyma and ligation of abnormal feeding vessel. The first patient was a 44-year-old gentleman with recurrent bouts of cough for 2 years. Courses of antibiotics failed to resolve it. Fibreoptic bronchoscopy and routine blood tests did not show any abnormality. CECT chest showed multiloculated cystic solid and low density mass in the right lower lung. The area of the lesion received its blood supply from anomalous systemic artery originating from coeliac trunk. Intraoperative, indocyanine green was injected into the atypical vessel, and pulmonary sequestration turned green. A sequential atypical lung resection could be completely removed with parenchyma preservation. The second patient was a 53-year-old lady presenting with chest pain, cough and expectoration for 2 years not responding to general management and antibiotics. CECT showed a low-density mass in the right lower lung lobe, with a feeding arterial vessel arising from the abdominal aorta. This was diagnosed as PS and resected using per-operative indocyanine green with parenchymal preservation and ligation of feeding vessel. Both patients have been followed up for at least 1 year and are symptom free. The intraoperative use of indocyanine green could greatly facilitate the presentation of the extent of a lung sequestration and safe resection.
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Ghazy AR, Shalaby MG, Ibrahim A, ElShaer A, Mahmoud YAG, Al-Hossainy AF. Synthesis, structural and optical properties of Fungal biosynthesized Cu2O nanoparticles doped Poly methyl methacrylate -co- Acrylonitrile copolymer nanocomposite films using experimental data and TD-DFT/DMOl3 computations. J Mol Struct 2022. [DOI: 10.1016/j.molstruc.2022.133776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Kadir R, Gegele T, Kola-Taiwo I, Ayewole A, Ibrahim A, Imam A, Chengetanai S, Ajao M. Memory, neurogenic protein and oxidative deficits of frontal cortex following chlorpyrifos/dichlorvos exposure in rats. RESEARCH JOURNAL OF HEALTH SCIENCES 2022. [DOI: 10.4314/rejhs.v10i2.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Ibrahim A, Alarfaj SJ, Alsantly A, Alfaran D, Alenezi M, Almutairi R. community pharmacists’ experiences and beliefs towards providing pharmacy services to deaf and hard of hearing patients: a mixed-method study in Riyadh, Saudi Arabia. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2022. [DOI: 10.1093/ijpp/riac019.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
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.
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Ramteke S, Muley G, Baig M, Ibrahim A, Aslam Manthrammel M, Muzammil K, Shkir M, Anis M. Optimizing growth, linear and 3rd order nonlinear optical traits of potassium aluminium sulfate (KAS) crystal by tuning pH for photonic device applications. INORG CHEM COMMUN 2022. [DOI: 10.1016/j.inoche.2022.109484] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Elhassan A, Ibrahim A, Saad M, Awad K, Salman M, Mohammed O, Ali M, Bashir S, Mohamed N, Mohammed M. 257 Comparing Practice Testing to Restudying in the Dissecting Room: An Experimental Study. Br J Surg 2022. [DOI: 10.1093/bjs/znac039.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
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.
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Ibrahim A, Elhassan A, Salman M, Mohammed O, Bashir S, Mohamed N, Ali M, Awad K, Abdelkarem A. 259 Effect of Telegram Videos on Anatomy Education Among 2nd Year Medical Students, University of Khartoum, 2021. Br J Surg 2022. [PMCID: PMC9383538 DOI: 10.1093/bjs/znac039.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
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.
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Elhassan A, Ibrahim A, Salman M, Ali A, Mohammed O, Bashir S, Mohamed N, Ali M, Abdalla N. 255 An Audit on the Knowledge of Junior Doctors About DKA at a Local Hospital, Khartoum, Sudan. Br J Surg 2022. [DOI: 10.1093/bjs/znac039.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
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.
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Granzier RWY, Ibrahim A, Primakov S, Keek SA, Halilaj I, Zwanenburg A, Engelen SME, Lobbes MBI, Lambin P, Woodruff HC, Smidt ML. Test-Retest Data for the Assessment of Breast MRI Radiomic Feature Repeatability. J Magn Reson Imaging 2021; 56:592-604. [PMID: 34936160 PMCID: PMC9544420 DOI: 10.1002/jmri.28027] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/03/2021] [Accepted: 12/03/2021] [Indexed: 12/14/2022] Open
Abstract
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
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Lau C, Shabbir A, Rathod KS, Chhetri I, Ono M, Hamers AJP, Amarin JJ, Ibrahim A, Nuredini G, Godec T, Kapil V, Ahluwalia A. Inorganic nitrate attenuates endothelial dysfunction consequent to systemic inflammation. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
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<0.0001) compared to placebo. There were significant increases in urine nitrite (p<0.0001) and nitrate (p<0.0001) in addition to salivary nitrite (p<0.0001) and nitrate (p<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
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Rojoa D, Raheman F, Ibrahim A, Patel N. 280 The Use of Telemedicine in Plastics Surgery During COVID-19: A Single-Centre Correlation Study with Patient Reported Outcome Measures. Br J Surg 2021. [PMCID: PMC8524559 DOI: 10.1093/bjs/znab259.449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Ibrahim A, Elkhidir O, A’lam Elhuda D, Elhassan A, Salman M, Ali A, Elkhidir I, Abuzied A, Elhassan M, Mohammed O, Noureddin A. 1255 Crowdedness and Consequences of Long Waiting Time in Public and Private Health Centers Among Patients in Khartoum State, Sudan - 2016. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
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.
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Azab IHE, Thabet H, Almotairi S, Saleh M, Mogharbel R, Mahmoud S, El-Rayyes A, Ibrahim A, Zoromba M, Abdel‑Aziz M, Ibrahim S, Al-Hossainy A. Synthesis of a novel coumarin heterocyclic derivative and fabrication of hybrid nanocomposite thin film with CoOFe2O4 for optoelectronic applications. J Mol Struct 2021. [DOI: 10.1016/j.molstruc.2021.130640] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Ibrahim A, Aly W, Abd-Elmoneim A. DETERMINING WATER REQUIREMENTS FOR ACALYPHA WILKESIANA SHRUBS IN RELATION TO GROWING MEDIUM MIXTURE. SCIENTIFIC JOURNAL OF FLOWERS AND ORNAMENTAL PLANTS 2021; 8:291-308. [DOI: 10.21608/sjfop.2021.198625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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A. N, Ibrahim A, Negm M, Abd El-Karim D. Quality Assessment of Some Newly Produced Egyptian Cotton Varieties. EGYPTIAN ACADEMIC JOURNAL OF BIOLOGICAL SCIENCES, H. BOTANY 2021. [DOI: 10.21608/eajbsh.2021.192802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Bisson KM, Boss E, Werdell PJ, Ibrahim A, Frouin R, Behrenfeld MJ. Seasonal bias in global ocean color observations. APPLIED OPTICS 2021; 60:6978-6988. [PMID: 34613181 PMCID: PMC8500483 DOI: 10.1364/ao.426137] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/01/2021] [Indexed: 06/13/2023]
Abstract
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.
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Abd-Raboh E, Ibrahim A. Computer Control in Power Systems.(Dept.E). MEJ. MANSOURA ENGINEERING JOURNAL 2021; 16:151-161. [DOI: 10.21608/bfemu.2021.187971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Purkayastha P, Ibrahim A, Haslen D, Gamma R. The efficacy and safety of a nurse-led electrical cardioversion service for atrial fibrillation over a two-year time period. Eur J Cardiovasc Nurs 2021. [DOI: 10.1093/eurjcn/zvab060.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
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<0.05). We did not find a significant difference in cardioversion success rates between males and females (χ2 = 1.651; p = 0.199; α<0.05); nor did we witness a significant impact from the presence of ischaemic heart disease (χ2 = 1.545; p = 0.214; α<0.05) or hypertension (χ2 = 2.075; p = 0.150; α<0.05). Similarly, we found negligible impact of LV ejection fraction (χ2 = 1.494; p = 0.684; α<0.05) or LA size (χ2 = 1.310; p = 0.727; α<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<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.
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Ibrahim A, Buket Basmanav F, Bohelay G, Lévy A, Betz RC, Caux F. Atrichia with papular lesions: a differential diagnosis of alopecia universalis not to be missed. J Eur Acad Dermatol Venereol 2021; 35:e801-e803. [PMID: 34169584 DOI: 10.1111/jdv.17479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ibrahim A, Touma N, Al Shammari A, Carrier S, Aubé-Peterkin M. GreenLight laser prostatectomy: Are outcomes sustainable after a decade of surgery? A single center experience with up to 15 years’ follow-up. Eur Urol 2021. [DOI: 10.1016/s0302-2838(21)00477-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Jimoh O, Aliyu S, Ejembi J, Abdulaziz MM, Ibrahim M, Ibrahim A, Olayinka AT. Changing susceptibility pattern of Neisseria Gonorrhoeae: A threat to management of sexually transmitted infections - Case series. Niger J Clin Pract 2021; 24:778-781. [PMID: 34018990 DOI: 10.4103/njcp.njcp_444_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Elhassan ABE, Mohamed S, Ali A, Elbathani M, Abdallah O, Mohamed A, Ibrahim A, Salman M, Elni M, Elhassa M, Elkhidi I, Abuzie A. 388 Detection of Cytomegalovirus Infection in Infants with Biliary Atresia: A Meta-analysis. Br J Surg 2021. [DOI: 10.1093/bjs/znab134.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
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.
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Ibrahim A, Loseva V, Rodriguez R. A Case of T3 Thyrotoxicosis With Concomitant Follicular Thyroid Carcinoma. J Endocr Soc 2021. [PMCID: PMC8090334 DOI: 10.1210/jendso/bvab048.1793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Introduction: The coexistence of hyperthyroidism and thyroid cancer is considered a rare event. In these cases, the follicular thyroid carcinoma subtype is an even more rare finding. It is highly unlikely to find follicular carcinoma in a hyperactive thyroid nodule. Clinical Case: We report a case of an 85-year-old female with a past medical history of atrial fibrillation presenting to the clinic after she has noticed enlargement of her neck two weeks prior. The patient was seen by her primary care physician who ordered a CT neck that revealed a goiter and the patient was subsequently referred to our clinic. On further questioning, the patient denied palpitations, sweats, difficulty swallowing, heat or cold intolerance, weight changes, bowel changes, or any other complaints. The patient denied any prior history of thyroid disease or exposure to goitrogens. Her past medical history was not significant for any auto-immune related diseases. She denied any family history of thyroid disease or malignancy. On physical examination, the patient had a normal eye exam and mild goiter with a small palpated right thyroid nodule. Initial thyroid ultrasound revealed a heterogenous right lobe measuring 7.1 cm x 7.3 cm x 5.9 cm with one superior nodule measuring 1.3 cm x 0.7 cm x 0.8 cm and a heterogenous left lobe measuring 2.0 cm x 1.5 cm x 1.1 cm. Laboratory blood work up revealed total T4 of 10.5 μg/dL(normal: 5.0 to 12.0μg/dL), elevated total T3 at 322 ng/dl (normal: 80-220 ng/dL), suppressed TSH <0.01 uIU/mL (normal: 0.40-4.00 uIU/mL), markedly elevated thyroglobulin 2828 ng/mL(normal: 1-84 ng/mL), as well as elevated anti-TPO Ab 63.5 IU/mL (10.0-35.0 IU/mL). The patient underwent a thyroid uptake scan that revealed increased uptake in the right lobe. Three months after presentation, the patient underwent fine-needle aspiration (FNA) which was benign (Bethesda classification II). A decision was made to start the patient on Methimazole and the subsequent thyroid profile showed an improvement in her T3 and TSH, but thyroglobulin continued to uptrend despite treatment. The patient then underwent another thyroid ultrasound one year later that revealed increased right lobe size to 10.3 cm x 6.3 cm x 6.4 cm with enlargement of the superior nodule to 8.5 cm x 4.6 cm x 6.4 cm. The left lobe was also enlarged from the prior scan measuring 3.9 cm x 1.2 cm x 1.0 cm. The patient underwent a second FNA from that nodule which also revealed benign hyperplastic nodule (Bethesda classification II). Despite the benign FNA finding, a decision was made to perform genetic testing given the rapid progressive enlargement of the nodule. The genetic testing revealed TERT promoter gene mutation with a high risk for malignancy. The patient then underwent total thyroidectomy and the pathological analysis showed a 9 cm follicular thyroid carcinoma of the right nodule. The patient then underwent successful I-131 radioactive Iodine ablation. Subsequent thyroid ultrasounds were negative and TSH continued to downtrend while the patient continued to take thyroid hormone replacement. This patient’s presentation is unique in many aspects. The patient presented with a hyperactive hot nodule while follicular carcinoma of the thyroid gland is typically associated with clinical euthyroidism and a scan showing a cold nodule(1). In a study of 425 hyperthyroid patients, thyroid cancer was diagnosed in 7 (1.65%) hyperthyroid patients, and histological examination revealed the presence of papillary carcinoma in 5 cases and follicular carcinoma in only 2 cases (2). Our patient also had two negative FNAs despite the presence of follicular carcinoma. Hence, we are shedding the light on the importance of genetic testing in the setting of negative FNA for rapidly enlarging thyroid nodules. Conclusion: We urge physician’s awareness that on rare occasions, follicular thyroid carcinoma can be present in a hyperactive thyroid with a hot nodule. In the presence of negative FNA, hyperfunctioning rapidly growing thyroid nodules should be carefully evaluated by further genetic testing for the presence of concurrent malignancy. References: (1) Yunta PJ, Ponce JL, Prieto M, Lopez-Aznar D, Sancho-Fornos S: Solitary adrenal gland metastasis of a follicular thyroid carcinoma presenting with hyperthyroidism. Ann Endocrinol 2001;62:226-229 (2) Raimondo Gabriele, Departments of Surgery ‘Pietro Valdoni’: Thyroid Cancer in Patients with Hyperthyroidism. Horm Res 2003;60:79-83 DOI: 10.1159/000071875
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Ibrahim A, Loseva V. A Case of Thyroid Eye Disease Revealed During Secondary Adrenal Insufficiency. J Endocr Soc 2021. [PMCID: PMC8090127 DOI: 10.1210/jendso/bvab048.1858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: Thyroid eye disease (TED) or Graves’ orbitopathy (GO) is an autoimmune disease of the retro-orbital tissues. GO is mostly associated with hyperthyroidism in 90% of patients; however, it may coexist with hypothyroid conditions in 5% of cases. Clinical Case: A 56-year-old male with a past medical history of autoimmune diseases including hypothyroidism and Ulcerative Colitis on chronic steroid therapy presented to the emergency department with nausea, fatigue, weight loss, and muscle weakness. The patient stated that his glucocorticoids were abruptly discontinued a month prior to his current presentation. On examination, vitals were stable. The patient was somnolent with a depressed mood. He had bilateral periorbital edema and bilateral eyeball protrusion, left more pronounced than right. Extraocular muscle movement revealed a delay in the lateral movement of the left eye causing double vision on exam. He had no starring look or lid lag. The thyroid gland was normal in size and contour. Initial Laboratories revealed a white blood cell count of 6.7 K/mcL (4-10 K/mcL) with 18% eosinophil count (0-5%). Cortisol at 8 AM was 2.9 mcg/dL (4.3 -22.4 mcg/dl). The patient was managed for secondary adrenal insufficiency and restarted immediately on Prednisone. A review of a recent CT scan of the head revealed bilateral proptosis with no signs of compressing lesions. Further thyroid studies revealed TSH of 2.9 mcIU/mL (0.3-3.7 mcIU/mL), free T4 of 0.8 ng/dL (0.75-2.0 ng/dL), free T3 of 1.6 ng/dL (2.4-4.2 ng/dL), TPO antibodies <0.3 IU/mL (0.0-9.0 IU/mL) and TSH receptor antibodies 0.90 IU/L (reference range <1.75 IU/L). The patient was then diagnosed with Hypothyroid Grave’s ophthalmopathy with negative antibodies given the evidence of proptosis on CT and exam revealing extraocular muscle movement restriction causing diplopia. The patient had a unique presentation of TED with hypothyroidism and asymmetric ophthalmic signs that were only manifested after the patient discontinued the prednisone and therefore unmasking the underlying disorder. Fortunately, in June of 2020, the US Food and Drug Administration (FDA) approved Teprotumumab (an insulin-like growth factor 1 [IGF-1] receptor inhibitor) for the treatment of Graves’ orbitopathy based on the findings from two 24-week trials comparing teprotumumab with placebo in 171 patients with active, moderate-to-severe orbitopathy. (1) Our patient was started on Levothyroxine along with Prednisone and referred for ophthalmology evaluation for possible qualification for Teprotumumab treatment. Conclusion: Clinician awareness of the unusual presentations of TED would allow for early recognition and prevention of progression, especially with the recently approved treatment modality. References: (1) Teprotumumab for Thyroid-Associated Ophthalmopathy. Smith TJ Et al. N Engl J Med. 2017;376(18):1748.
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