Avoidable emergency department visits among palliative care cancer patients: novel insights from Saudi Arabia and the Middle East

BACKGROUND

Several studies emerging from developed countries have highlighted a significant number of potentially avoidable emergency department (ED) visits by cancer patients during the end-of-life period. However, there is a paucity of information from developing nations regarding palliative care practices and the utilization of the ED by palliative care patients. Herein, we aim to characterize ED admissions among patients receiving palliative care at our tertiary center in Saudi Arabia.

METHODS

This is a retrospective, cross-sectional study evaluating ED visits amongst adult patients with advanced cancer who were receiving treatment under the palliative care department. This study took place over a period of 12 months from July 2021 through to July 2022. Three palliative care specialist physicians independently and blindly reviewed each patient's ED visits and determined whether the visit was avoidable or unavoidable.

RESULTS

A total of 243 patients were included in the final analysis, of which 189 (78.1%) patients had unavoidable visits and 53 (21.9%) patient visits were classified as avoidable. A significantly higher proportion of breast cancer patients presented with unavoidable admissions (14.3% vs. 3.8%, P = 0.037) compared to other cancer types. The incidence of dyspnea (23.8% vs. 5.7%, P < 0.001) and fevers/chills (23.3% vs. 5.7%, P = 0.005) was significantly higher in patients with unavoidable visits. Patients with avoidable visits had a significantly greater proportion of visits for dehydration (13.2% vs. 2.1%, P = 0.002). Notably, although hospital stay was significantly longer in the unavoidable group (P = 0.045), mortality for palliative care patients-regardless of whether their ED visit was avoidable or unavoidable-was not statistically different (P=-0.069).

CONCLUSION

To our knowledge, this is the largest and most comprehensive study from Saudi Arabia and the Middle East providing insights into the utilization of palliative care services in the region and the propensity of advanced cancer patients towards visiting the ED. Future studies ought to explore interventions to reduce the frequency of avoidable ED visits.

Risk Factors for Postoperative Infections in Cardiac Surgery Patients: A Retrospective Study

Background and objective Cardiac surgery is one of the most common surgical procedures globally; its incidence has been on the rise due to the faster pace of population aging thanks to technological and epidemiological advances. Patients who undergo cardiac surgeries may face various postoperative complications that might affect their survival, and one of these major complications is infection. Nosocomial pneumonia, surgical site infection (SSI), mediastinitis, bacteremia, and sepsis are common infections encountered after surgeries. In this study, we aimed to determine the common risk factors related to postoperative infections at the King Faisal Cardiac Center from January 2014 to September 2020. Materials and methods  Records from 364 patients who underwent cardiac surgery and were aged above 18 years were assessed for postoperative infections in this retrospective cohort study. Patients who were immunosuppressed or had active systemic infections were excluded. Consent was waived by the Institutional Review Board. All procedures were performed at the King Faisal Cardiac Center, National Guard Hospital, Jeddah. Results Of the total 364 patients, 105 were women and 259 were men. The mean age of the cohort was 59 years (SD = 13) and the mean BMI was 29.1 kg/m2 (SD = 5.3). The study population showed a high prevalence of cardiac risk factors and diseases: diabetes (n = 244, 67%), hypertension (n = 230, 63%), dyslipidemia (n = 144, 40%), smoking (n = 80, 22%), heart failure (n = 41, 11%), and chronic obstructive pulmonary disease (n = 6, 1.6%). The overall rate of postoperative infection was 32.7% (n = 120), and 17 (14%) of these infected patients underwent reoperations for infection. Conclusion Based on a thorough analysis of 364 patients undergoing various cardiac surgical procedures, including a multivariate analysis accounting for preoperative factors, there was a significant association between postoperative infections and hypertension, diabetes, increased preoperative activated partial thromboplastin time, and elevated HbA1c.

Awareness of chronic obstructive pulmonary disease (COPD) among the general population in Aseer Region, Kingdom of Saudi Arabia (KSA)

Background

Chronic obstructive pulmonary disease (COPD) is a common but preventable disease and has a prevalence of 5%-14% in the general population. It is characterized by airflow limitation and persistent respiratory symptoms. In this survey, we aimed to assess the awareness of COPD among the general population in the Aseer Region of the Kingdom of Saudi Arabia (KSA).

Method

This was an observational, cross-sectional study in which predesigned electronic questionnaires were distributed to 504 randomly selected community personnel utilizing phone services. The collected data were analyzed using the IBM SPSS Statistics software, version 24 for Windows (IBM Corp., Armonk, NY).

Results

Participants were asked 11 questions with yes-or-no answers based on awareness and symptoms of COPD: 35.5% of participants had heard about the COPD as a term and 72% had no detailed information about COPD. Only 3.5% of participants had relatives with COPD. During the survey on COPD symptoms, 31% of participants chose shortness of breath and the rest chose cough (20%), sputum production (15%), wheezing (14%), and chest pain (19%). Almost two-third of the participants had no idea about COPD symptoms. For the most disease knowledge, majority of the study participants had very poor knowledge about the disease that was evident in the 22 questions intended to assess this domain. Social media sites ranked as the most popular source of information on COPD among the study participants.

Conclusion

Awareness about COPD among the general population in the Aseer Region in KSA is poor. It is advisable to carry out programs to increase their level of awareness.

Generalized morphea following COVID-19 vaccine: Case report and literature review

Physicians should be vigilant for COVID-19 vaccine side effects and investigate any associated cutaneous manifestations. This will ultimately facilitate better understanding and recognition of various skin reactions related to the vaccine.

A security testing mechanism for detecting attacks in distributed software applications using blockchain

Distributed software applications are one of the most important applications currently used. Rising demand has led to a rapid increase in the number and complexity of distributed software applications. Such applications are also more vulnerable to different types of attacks due to their distributed nature. Detecting and addressing attacks is an open issue concerning distributed software applications. This paper proposes a new mechanism that uses blockchain technology to devise a security testing mechanism to detect attacks on distributed software applications. The proposed mechanism can detect several categories of attacks, such as denial-of-service attacks, malware and others. The process starts by creating a static blockchain (Blockchain Level 1) that stores the software application sequence obtained using software testing techniques. This sequence information exposes weaknesses in the application code. When the application is executed, a dynamic blockchain (Blockchain Level 2) helps create a static blockchain for recording the responses expected from the application. Every response should be validated using the proposed consensus mechanism associated with static and dynamic blockchains. Valid responses indicate the absence of attacks, while invalid responses denote attacks.

A Multiband Shared Aperture MIMO Antenna for Millimeter-Wave and Sub-6GHz 5G Applications

A shared aperture 2-element multiple-input-multiple-output (MIMO) antenna design for 5G standards is presented in this study, one which uses the same radiating structure to cover both the sub-6GHz and millimeter-wave (millimeter-wave) bands. The proposed antenna comprises four concentric pentagonal slots that are uniformly separated from one another. For the sub-6GHz band, the antenna is excited by a single open-end microstrip transmission-line, while a 1 × 8 power divider (PD) connected via a T-junction structure excites the millimeter-wave band. Both the sub-6GHz and mm-wave antennas operate in a MIMO configuration. The proposed antenna design was fabricated on a 120 × 60 mm² substrate with an edge-to-edge distance of 49 mm. The proposed sub-6GHz antenna covers the following frequency bands: 4-4.5 GHz, 3.1-3.8 GHz, 2.48-2.9 GHz, 1.82-2.14 GHz, and 1.4-1.58 GHz, while the millimeter-wave antenna operates at 28 GHz with at least 500 MHz of bandwidth. A complete antenna analysis is provided via a step-by-step design procedure, an equivalent circuit diagram showing the operation of the shared aperture antenna, and current density analysis at both millimeter-wave and sub-6GHz bands. The proposed antenna design is also characterized in terms of MIMO performance metrics with a good MIMO operation with maximum envelop correlation coefficient value of 0.113. The maximum measured gain and efficiency values obtained were 91% and 8.5 dBi over the entire band of operation. The antenna is backward compatible with 4G bands and also encompasses the sub-6GHz and 28 GHz bands for future 5G wireless communcation systems.

The Effect of Self-Reported Diabetes on Alveolar Bone Loss and Number of Missing Teeth

Background:

Diabetes mellitus, a major public health problem worldwide, is a known risk factor for periodontitis.

Objective:

This study aimed to investigate the effect of diabetes on periodontal health in a Saudi population by assessing alveolar bone level, and the number of missing teeth.

Methods:

In this retrospective study, the dental records of 203 patients (30–70 years old) patients (diabetic group = 102; control = 101) who visited King Abdulaziz University, Faculty of Dentistry, were examined through panoramic radiography. Bone loss measurements were carried out using the Ramfjord teeth index, and the number of missing teeth was counted for both groups. Independent t-test was used for comparing the total average represented by two group means, while Chi-square test was utilized to establish relationships between categorical variables.

Results:

The diabetic group had a significant 1.35-fold higher mean total bone loss (3.59 ± 1.37) compared to the control (2.66 ± 1.05). This was statistically significant in both genders (p = 001) and in >45 years old age group (p <0.05). The number of missing teeth was significantly higher in diabetic patients compared to control patients, specifically when missing >10 teeth and belonging to >55 years old age group (p <0.05).

Conclusion:

Our findings have shown a positive association between periodontal disease and diabetic patients, emphasizing the importance of early screening and diagnosis of diabetes and periodontitis in Saudi Arabia, which would help patients to avoid alveolar bone and tooth loss at early stages.

Hepatic focal nodular hyperplasia in a five-year-old healthy boy: A case report and literature review

Introduction: Focal nodular hyperplasia is unusually seen in a pediatric age group, with few reported cases in the literature. We report the case of a 5-year-old boy not known to have medical illnesses, who was found to have a liver mass, underwent right trisectionectomy. The purpose of this report is to familiarize the healthcare community with similar events, review the literature, and discuss recommendations for future similar cases. Case Report: A case of focal nodular hyperplasia (FNH) in a 5-year-old healthy boy who was found to have a huge liver lesion on ultrasound imaging due to a vague abdominal pain and distension. The patient underwent surgical excision of the mass due to abdominal pain, distension, and atypical features of FNH in radiological examinations. Histopathological analysis revealed a focal nodular hyperplasia. Conclusion: Focal nodular hyperplasia considered a benign lesion that has no malignant transformation. The presenting symptoms are variable, usually asymptomatic. Laboratory tests have of little significance. Imaging modalities mainly ultrasound scan initially then magnetic resonance imaging (MRI) are useful to obtain more accurate characteristic features of the lesion. Uncertain diagnostic lesion needs to be biopsied and examined under microscopy. Confirming the diagnosis will follow an acceptable conservative management approach. Surgical resection is the preferred method in uncertain, questionable, or atypical features observed in radiological imaging.

COVID-19 Psychological Impact on Health Care Workers in Saudi Arabia

OBJECTIVE

Little is known about the impact of Coronavirus (COVID-19) among the health care workers in Saudi Arabia. Therefore, the present study aimed to assess the psychological impact of COVID-19 among the health care workers.

METHODS

A cross-sectional survey was conducted from May till mid-July among 389 health care workers from government and private hospitals in Saudi Arabia. Data was collected using a pre-structured online questionnaire that measured adverse psychological outcomes, including the Patient Health Questionnaire-9 (PHQ-9) scale and the Generalized Anxiety Disorder 7-item (GAD-7) scale. The Pearson chi-square test was used to assess the distribution of depression and anxiety among health care workers.

RESULTS

A high level of anxiety was recorded among the health care workers, and 69.3% of health care workers below the age of 40 were found to have depression. There was a significant increase in depression among staff with chronic health problems (72.1% vs. 61.9%; p = 0.048). High anxiety levels were detected among young staff compared to others (68.7% vs. 43.8%; p = 0.001). Moreover, 82.1% of the female staff were anxious, as compared to 55.6% of the males (p = 0.001).

CONCLUSIONS

We found increased prevalence of adverse psychological outcomes among the health care workers in Saudi Arabia during the outbreak of COVID-19. Therefore, there is a need for proper screening and development of corresponding preventive measures to decrease the adverse psychological outcomes.

Prevalence of Depression, Anxiety, and Stress among the General Population in Saudi Arabia during Covid-19 Pandemic

Coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on public mental health. Our objective was to assess prevalence of depression, anxiety, and stress among the general population in Saudi Arabia during this pandemic. A descriptive cross-sectional approach was used targeting all accessible populations in Saudi Arabia. Data were collected from participants using an electronic pre-structured questionnaire. Psychological impact was assessed using the Arabic version of Depression, Anxiety, and Stress Scale (DASS-21). A total of 1597 participants completed the survey. In total, 17.1% reported moderate to severe depressive symptoms; 10% reported moderate to severe anxiety symptoms; and 12% reported moderate to severe stress levels. Depression, anxiety, and stress were significantly higher among females, younger respondents, and health care providers. Depression was higher among smokers, singles, and non-working respondents. Anxiety was higher among those reporting contacts with COVID-19 positive cases, previously quarantined and those with chronic health problems. Our findings reaffirm the importance of providing appropriate knowledge and specialized interventions to promote the mental well-being of the Saudi population, paying particular attention to high-risk groups.

Attribute based honey encryption algorithm for securing big data: Hadoop distributed file system perspective

Hadoop has become a promising platform to reliably process and store big data. It provides flexible and low cost services to huge data through Hadoop Distributed File System (HDFS) storage. Unfortunately, absence of any inherent security mechanism in Hadoop increases the possibility of malicious attacks on the data processed or stored through Hadoop. In this scenario, securing the data stored in HDFS becomes a challenging task. Hence, researchers and practitioners have intensified their efforts in working on mechanisms that would protect user's information collated in HDFS. This has led to the development of numerous encryption-decryption algorithms but their performance decreases as the file size increases. In the present study, the authors have enlisted a methodology to solve the issue of data security in Hadoop storage. The authors have integrated Attribute Based Encryption with the honey encryption on Hadoop, i.e., Attribute Based Honey Encryption (ABHE). This approach works on files that are encoded inside the HDFS and decoded inside the Mapper. In addition, the authors have evaluated the proposed ABHE algorithm by performing encryption-decryption on different sizes of files and have compared the same with existing ones including AES and AES with OTP algorithms. The ABHE algorithm shows considerable improvement in performance during the encryption-decryption of files.

Reduction of Red and Processed Meat Intake and Cancer Mortality and Incidence: A Systematic Review and Meta-analysis of Cohort Studies

This article has been corrected. The original version (PDF) is appended to this article as a Supplement.

BACKGROUND

Cancer incidence has continuously increased over the past few centuries and represents a major health burden worldwide.

PURPOSE

To evaluate the possible causal relationship between intake of red and processed meat and cancer mortality and incidence.

DATA SOURCES

Embase, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, and ProQuest from inception until July 2018 and MEDLINE from inception until April 2019 without language restrictions.

STUDY SELECTION

Cohort studies that included more than 1000 adults and reported the association between consumption of unprocessed red and processed meat and cancer mortality and incidence.

DATA EXTRACTION

Teams of 2 reviewers independently extracted data and assessed risk of bias; 1 reviewer evaluated the certainty of evidence, which was confirmed or revised by the senior reviewer.

DATA SYNTHESIS

Of 118 articles (56 cohorts) with more than 6 million participants, 73 articles were eligible for the dose-response meta-analyses, 30 addressed cancer mortality, and 80 reported cancer incidence. Low-certainty evidence suggested that an intake reduction of 3 servings of unprocessed meat per week was associated with a very small reduction in overall cancer mortality over a lifetime. Evidence of low to very low certainty suggested that each intake reduction of 3 servings of processed meat per week was associated with very small decreases in overall cancer mortality over a lifetime; prostate cancer mortality; and incidence of esophageal, colorectal, and breast cancer.

LIMITATION

Limited causal inferences due to residual confounding in observational studies, risk of bias due to limitations in diet assessment and adjustment for confounders, recall bias in dietary assessment, and insufficient data for planned subgroup analyses.

CONCLUSION

The possible absolute effects of red and processed meat consumption on cancer mortality and incidence are very small, and the certainty of evidence is low to very low.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42017074074).

PO-48 - Assessment of the procoagulant potential state of tumour-MP in cancer patients

INTRODUCTION

The venous thromboembolism is considered one of the highest risk factor in cancer patients for instance ovarian and pancreas. This hypercoagulability state is believed to be caused by tumour cells that can produce a variety of procaogulant factors including tissue factor (TF) bearing microparticles (MP). Chemotherapy is an independent risk factor for venous thromboembolism (VTE) in patients and it can leads to coagulation activation and may increase microparticles that can increase risk of thrombosis.

AIM

Therefore, our current hypothesis is that this increased risk of VTE is due to release of tumour MP into the blood. To further investigate this mechanism an ex-vivo microfluidic model system was developed wherein tumour spheroids were grown and transferred onto a microfluidic chip and assessed, under flow conditions, for procoagulant activity (PCA).

MATERIALS AND METHODS

Tumour spheroids from pancreatic cancer cell line AsPC1 and human glioblastoma cell line U87 were generated using the liquid overlay method in a 96-well plate, then transferred to a microfluidic chip, designed with a trap within the device to immobilise the spheroid. The procoagulant potential of cell-free supernatant was measured using a prothrombin time clotting assay. Procoagulant activity was assessed under flow rate of 3.0 μL min-1 for 6 hours.

RESULTS

Several tumour cell lines (A2780, SKOV3, MIA Paca2, AsPC1 and U87) were assessed for PCA of media (MP associated) and then subsequently assessed for spheroid formation. Prothrombin time of cell-free media was A2780: 794s, SKOV3: 203.4s, MIA Paca2: 412s, AsPC1: 69s and U87: 50.3s. The pancreatic cell line AsPC-1 and glioblastoma cell line U87 were selected for further study on the basis of relatively high PCA and ability to form stable spheroids. When transferred to a microfluidic chip, AsPC1 tumour spheroids showed a slowing of PCA of media over a 6-hour period from 36.6 to 309s. U87 tumour spheroids showed a reduction in PCA of media over a 6-hour period from 51.3 to 108.9s.

CONCLUSIONS

This is the first report of tumour spheroids maintained in a microfluidic device and then subsequently assessed for PCA. Tumour spheroids of AsPC1 were shown to produce continuous procaogulant activity and this is presumably due to tumour microparticle release. This new model system offers a way to assess tumour associated PCA under flow conditions.

Feasibility and safety of day-surgery laparoscopic cholecystectomy: a single-institution 5-year experience of 1140 cases

Backgrounds/Aims

We report our experience with day-surgery laparoscopic cholecystectomy and assess its feasibility and safety.

Methods

Data was collected on all the patients who underwent day-surgery laparoscopic cholecystectomy between February 2009 and February 2014 at Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia. All patients had symptomatic cholelithiasis that was proven on imaging studies with clearance of the common bile duct. The patient biographical data (age, gender, American Society of Anaesthesiology status, medical comorbidities) and surgical outcomes were then obtained. There was an evaluation of the success rate of day-surgery laparoscopic cholecystectomy, reasons for unexpected admission, and the re-admission rate.

Results

A total of 1,140 patients were included in this study. The success rate for day-surgery laparoscopic cholecystectomy was 96%. The reasons for unexpected hospital admission for 46 patients (4%) included persistent abdominal pain and postoperative emesis. The postoperative re-admission rate was 0.4% (5 patients). There were no major complications, and the conversion rate was 0.5% (6 patients).

Conclusions

We suggest that day-surgery laparoscopic cholecystectomy is both safe and feasible in a local setting. Careful patient selection is essential in ensuring a high success rate.

Tumor Characteristics and Long-Term Outcome of Incidental Hepatocellular Carcinoma After Orthotopic Liver Transplant

OBJECTIVES

Orthotopic liver transplant is the treatment of choice for hepatocellular carcinoma in cirrhotic patients with satisfactory oncologic and survival outcomes. Incidental hepatocellular carcinoma is frequently a reported finding in the explant pathology after orthotopic liver transplant.

MATERIAL AND METHODS

The present study retrospectively analyzed the tumor characteristics and outcomes of 50 incidental hepatocellular carcinomas compared with 252 transplants for known hepatocellular carcinoma.

RESULTS

Patients with incidental hepatocellular carcinoma had lower peak alpha-fetoprotein level (P = .001), lower pretransplant alpha-fetoprotein level (P = .002), smaller total tumor size (P = .0001), fewer tumor numbers (P = .0001), lower level of microvascular invasion (P = .001), more cases within Milan criteria (P = .005), and more well-differentiated tumors (P = .017). However, no difference in survival rates was observed between the 2 groups. In 35 patients (70%) who had incidental hepatocellular carcinoma, pretransplant imaging studies were normal; ultrasonography was used as the only screening tool in 25 of 35 patients (71%) who had incidental hepatocellular carcinoma, and 15 patients (30%) who had incidental hepatocellular carcinoma had regenerative or dysplastic nodules. The accuracy of ultrasonography in our unit for diagnosing hepatocellular carcinoma was 97.5%. A quarter of hepatitis B recipients had incidental hepatocellular carcinoma with a younger median recipient age. Tumor recurrence was higher with incidental hepatocellular carcinoma in hepatitis C recipients (22%). However, the overall recurrence was similar between all hepatitis and nonhepatitis recipients who were transplanted for incidental or known hepatocellular carcinoma.

CONCLUSIONS

Incidental hepatocellular carcinoma has similar outcome as known hepatocellular carcinoma. Early screening of hepatitis B patients is recommended, and cross-sectional imaging is not mandatory for hepatocellular carcinoma screening in patients who are on the waiting list.

Primary hepatic tuberculosis in immunocompetent adults: a UK case series

Primary hepatic tuberculosis (TB) is very rare in the UK, but the incidence may be rising. Three cases of primary hepatic TB in immunocompetent patients without evidence of pulmonary involvement are reported. The diagnosis was challenging as two patients had liver space-occupying lesions, and the third patient presented with liver abscess. All of them responded well to standard anti-tubercular treatment. Hepatic TB should be considered in the differential diagnosis of space-occupying lesions of the liver and liver abscesses.

Aetiology and risk factors of ischaemic cholangiopathy after liver transplantation

Liver transplantation (LT) is the best treatment for end-stage hepatic failure, with an excellent survival rates over the last decade. Biliary complications after LT pose a major challenge especially with the increasing number of procured organs after circulatory death. Ischaemic cholangiopathy (IC) is a set of disorders characterized by multiple diffuse strictures affecting the graft biliary system in the absence of hepatic artery thrombosis or stenosis. It commonly presents with cholestasis and cholangitis resulting in higher readmission rates, longer length of stay, repeated therapeutic interventions, and eventually re-transplantation with consequent effects on the patient’s quality of life and increased health care costs. The pathogenesis of IC is unclear and exhibits a higher prevalence with prolonged ischaemia time, donation after circulatory death (DCD), rejection, and cytomegalovirus infection. The majority of IC occurs within 12 mo after LT. Prolonged warm ischaemic times predispose to a profound injury with a subsequently higher prevalence of IC. Biliary complications and IC rates are between 16% and 29% in DCD grafts compared to between 3% and 17% in donation after brain death (DBD) grafts. The majority of ischaemic biliary lesions occur within 30 d in DCD compared to 90 d in DBD grafts following transplantation. However, there are many other risk factors for IC that should be considered. The benefits of DCD in expanding the donor pool are hindered by the higher incidence of IC with increased rates of re-transplantation. Careful donor selection and procurement might help to optimize the utilization of DCD grafts.