Barriers and facilitators to early mobilisation and weight-bearing as tolerated after hip fracture surgery among older adults in Saudi Arabia: a qualitative study

OBJECTIVE

To explore the practice of prescribing and implementing early mobilisation and weight-bearing as tolerated after hip fracture surgery in older adults and identify barriers and facilitators to their implementation.

METHODS

Semi-structured interviews were conducted with 20 healthcare providers (10 orthopaedic surgeons and 10 physiotherapists) from Saudi Arabian government hospitals. Data were analysed using inductive thematic analysis.

RESULTS

While early mobilisation and weight-bearing as tolerated were viewed as important by most participants, they highlighted barriers to the implementation of these practices. Most participants advocated for mobility within 48 h of surgery, aligning with international guidance; however, the implementation of weight-bearing as tolerated was varied. Some participants stressed the type of surgery undertaken as a key factor in weight-bearing prescription. For others, local protocols or clinician preference was seen as most important, the latter partially influenced by where they were trained. Interdisciplinary collaboration between orthopaedic surgeons and physiotherapists was seen as a crucial part of postoperative care and weight-bearing. Patient and family member buy-in was also noted as a key factor, as fear of further injury can impact a patient's adherence to weight-bearing prescriptions. Participants noted a lack of standardised postoperative protocols and the need for routine patient audits to better understand current practices and outcomes.

CONCLUSION

This study contributes to national and global discussions on the prescription of early mobilisation and weight-bearing as tolerated. It highlights the necessity for a harmonised approach, incorporating standardised, evidence-based protocols with patient-specific care, robust healthcare governance and routine audits and monitoring for quality assurance and better patient outcomes.

Managing Postharvest Losses of Vegetables and Fruits: A Methodological Review

Vegetables and fruits are highly perishable agricultural commodities cultivated all over the world. However, inadequate handling practices have led to significant postharvest losses of these agricultural commodities, as well as the wastage of valuable resources, such as time and money. Hence, it can be observed that cultivators often experience significant financial setbacks as a result of inadequate comprehension regarding the nature and origins of these losses, insufficient preservation practices, and ineffective approaches to transportation and marketing. In addition, the utilization of suitable chemical agents during both the pre- and postharvest phases has the potential to prolong the shelf life of agricultural products. This preservation technique safeguards vegetables and fruits from pathogenic organisms and other forms of environmental harm, thereby enabling their availability for an extended duration. Therefore, this review proposes a methodology for managing fruits and vegetables postharvest to minimize losses and optimize returns.

Decreased Seasonal Influenza Rates Detected in a Crowdsourced Influenza-Like Illness Surveillance System During the COVID-19 Pandemic: Prospective Cohort Study

BACKGROUND

Seasonal respiratory viruses had lower incidence during their 2019-2020 and 2020-2021 seasons, which overlapped with the COVID-19 pandemic. The widespread implementation of precautionary measures to prevent transmission of SARS-CoV-2 has been seen to also mitigate transmission of seasonal influenza. The COVID-19 pandemic also led to changes in care seeking and access. Participatory surveillance systems have historically captured mild illnesses that are often missed by surveillance systems that rely on encounters with a health care provider for detection.

OBJECTIVE

This study aimed to assess if a crowdsourced syndromic surveillance system capable of detecting mild influenza-like illness (ILI) also captured the globally observed decrease in ILI in the 2019-2020 and 2020-2021 influenza seasons, concurrent with the COVID-19 pandemic.

METHODS

Flu Near You (FNY) is a web-based participatory syndromic surveillance system that allows participants in the United States to report their health information using a brief weekly survey. Reminder emails are sent to registered FNY participants to report on their symptoms and the symptoms of household members. Guest participants may also report. ILI was defined as fever and sore throat or fever and cough. ILI rates were determined as the number of ILI reports over the total number of reports and assessed for the 2016-2017, 2017-2018, 2018-2019, 2019-2020, and 2020-2021 influenza seasons. Baseline season (2016-2017, 2017-2018, and 2018-2019) rates were compared to the 2019-2020 and 2020-2021 influenza seasons. Self-reported influenza diagnosis and vaccination status were captured and assessed as the total number of reported events over the total number of reports submitted. CIs for all proportions were calculated via a 1-sample test of proportions.

RESULTS

ILI was detected in 3.8% (32,239/848,878) of participants in the baseline seasons (2016-2019), 2.58% (7418/287,909) in the 2019-2020 season, and 0.27% (546/201,079) in the 2020-2021 season. Both influenza seasons that overlapped with the COVID-19 pandemic had lower ILI rates than the baseline seasons. ILI decline was observed during the months with widespread implementation of COVID-19 precautions, starting in February 2020. Self-reported influenza diagnoses decreased from early 2020 through the influenza season. Self-reported influenza positivity among ILI cases varied over the observed time period. Self-reported influenza vaccination rates in FNY were high across all observed seasons.

CONCLUSIONS

A decrease in ILI was detected in the crowdsourced FNY surveillance system during the 2019-2020 and 2020-2021 influenza seasons, mirroring trends observed in other influenza surveillance systems. Specifically, the months within seasons that overlapped with widespread pandemic precautions showed decreases in ILI and confirmed influenza. Concerns persist regarding respiratory pathogens re-emerging with changes to COVID-19 guidelines. Traditional surveillance is subject to changes in health care behaviors. Systems like FNY are uniquely situated to detect disease across disease severity and care seeking, providing key insights during public health emergencies.

Attitudes and Practices of the Public Toward Precautionary Measures Post-COVID-19 Pandemic in Saudi Arabia

Objective

This study aimed to assess the practices and attitudes of the general population towards coronavirus disease-2019 (COVID)-19 after the removal of precautionary and preventive measures in Saudi Arabia.

Methods

A cross-sectional study was conducted among the general population in all regions of the Kingdom of Saudi Arabia, from September 2022 to October, 2022 via a virtual survey to evaluate the practices, and attitudes of the general population towards COVID-19. A stratified random sampling technique was applied to collect the sample with inclusion criteria for all individuals who are Arabic language speakers using social media platforms. The individuals selected for this study were 18 years and older.

Results

A total of 2406 responses were received for the study questionnaire. Most of participants (66.3%) were females aged 18 to 29 years (61.8%). Half of the participants reported a positive history of COVID-19 infection. Nearly 90% of participants still wear masks, 80% attended a crowded event, and 60% often wash their hands even though the Saudi government has erased the precautions. Females, young (30-39 years) and elderly (60 years and over) individuals, singles, those with a postgraduate degree, those who are employed, and healthcare workers were more likely to adhere to COVID-19 precautionary measures (p<0.05).

Conclusion

The study's findings indicate that most of the population discontinued practicing precautionary measures after lifting the measures in Saudi Arabia. More public health initiatives should raise the scores of sanitary best practices to prevent the spread of viral illnesses.

Preisolation measures and clinical features for pediatric patients with suspicious COVID-19

Background

In December 2019, many cases of COVID-19 were reported in Wuhan City, Hubei Province, China. In the following 3 months, the disease out broke in China. Preisolation measures was used to screen out COVID-19 patients in the pediatric respiratory ward of our hospital.

Aims

To investigate the new measures for screening COVID-19 patients and to analyze the clinical features of children with suspicious COVID-19.

Methods

A total of 50 preisolated children with suspicious COVID-19 who were admitted to our hospital in Mianyang, China, between January 28 and March 5, 2020, were included. Patients presented with fever and cough or fever accompanied by vomiting and diarrhea. A detailed epidemiological history screening was performed. A real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) was used to detect SARS-COV-2 nucleic acid. Low-dose chest computed tomography (CT) was applied when pneumonia was suspicious. Routine blood tests were performed to rule out COVID-19. Patients' data were collected, and the basic clinical features, epidemiological history, clinical manifestations, auxiliary examination results, and outcomes were analyzed and summarized.

Results

No definite cases were detected, while two patients were suspected of having COVID-19. The pathogenic results of the 50 patients mainly included Mycoplasma pneumoniae, followed by Epstein-Barr virus, and rotavirus. Thirty-five patients suffered from bronchopneumonia. The preisolated patients had similar clinical and epidemiological characteristics as patients with fever, cough, vomiting, and diarrhea.

Conclusions

Preisolation measures combined with pathogen screening can minimize the risk of hospital-acquired infections by preventing patients with suspicious COVID-19 from contacting other patients before they are explicitly excluded. Clinical analysis of the patients was helpful for clinical nursing management.

Cereulide and Emetic Bacillus cereus: Characterizations, Impacts and Public Precautions

Cereulide, which can be produced by Bacillus cereus, is strongly associated with emetic-type food poisoning outbreaks. It is an extremely stable emetic toxin, which is unlikely to be inactivated by food processing. Considering the high toxicity of cereulide, its related hazards raise public concerns. A better understanding of the impact of B. cereus and cereulide is urgently needed to prevent contamination and toxin production, thereby protecting public health. Over the last decade, a wide range of research has been conducted regarding B. cereus and cereulide. Despite this, summarized information highlighting precautions at the public level involving the food industry, consumers and regulators is lacking. Therefore, the aim of the current review is to summarize the available data describing the characterizations and impacts of emetic B. cereus and cereulide; based on this information, precautions at the public level are proposed.

Compliance with precautions to reduce the spread of COVID-19 in Canada

BACKGROUND

Throughout the COVID-19 pandemic, Canadian public health officials have mandated and recommended precautions to slow the spread of COVID-19. This study examined which population groups were less compliant with precautions, such as mask-wearing and self-isolating, and where they were located in Canada.

DATA AND METHODS

Results are from the Canadian COVID-19 Antibody and Health Survey, a national survey aimed at estimating how many Canadians who were older than one year and living in private households had antibodies in their blood against the SARS-CoV-2 virus. Questionnaire data were collected in the 10 provinces and 3 territorial capitals, from November 2020 to April 2021. Respondents were asked about compliance with precautions related to COVID-19. Weighted prevalences and logistic regression models were used to identify which population groups were less compliant with precautions to prevent the spread of COVID-19, and where they were located in Canada.

RESULTS

Significant differences in compliance with precautions were found by sex, region, urban versus rural location, age, income, presence of chronic conditions, household size and work status. With covariate adjustment, Canadians who were less compliant with precautions were males, those living in the territorial capitals, those in rural areas, and people aged 34 and younger (compared with people aged 65 and older). Additional differences were found when analyzing compliance with consistently recommended precautions compared with those usually recommended.

INTERPRETATION

As Canada continues to navigate the waves of the pandemic, and with the emergence of new variants, precautions are still being mandated or recommended in many jurisdictions and locations. Continuing to understand which population groups were less compliant in earlier waves and where they were located in Canada can be beneficial to ongoing and future public health efforts to slow the transmission of COVID-19.

COVID-19 Precautions Experienced by a Sample of Adults with Intellectual and Developmental Disabilities

Purpose

This study describes factors associated with COVID-19 precautions (i.e., self-isolation and the use of personal protective equipment) among a sample of adults with intellectual and developmental disabilities (IDD) in Ontario, Canada.

Methods

The sample included 756 home care recipients with IDD who did not test positive for COVID-19 between March 2020 and July 2021. Among these, some received COVID-19 precautions. Precaution data were obtained from a large metropolitan organization serving persons with IDD in Ontario, and linked to home care assessment data. Unadjusted and adjusted odds ratios with 95% confidence intervals were calculated using logistic regression models to examine the association between COVID-19 cautions and demographic and clinical factors. Effect modification and interactions were explored.

Results

One hundred twenty-seven (16.8%) home care clients experienced precautions. After adjustment, congregate setting, aggression, and limited mobility were significantly associated with COVID-19 precautions. Age modified the relationship between congregate setting and precautions.

Conclusions

Pandemic responses need to recognize the impact on subgroups of adults with IDD, such as those living in congregate settings (including younger individuals) or engaging in responsive behaviors. How these precautions impacted individuals–in the short and long term–warrants further investigation.

What Has Changed in the Behaviors of the Public After the COVID-19 Pandemic? A Cross-Sectional Study From the Saudi Community Perspective

Background

Coronavirus disease-2019 (COVID-19) is caused by severe acute respiratory syndrome-coronavirus (SARS-CoV) and represents a major public health threat that aggressively promotes increased morbidity and mortality. Changes in public behavior were more common during the pandemic to protect against the infection. Suboptimal behavioral practices for a specific disease would increase the susceptibility of the public to infection. This study aimed to determine changes in behaviors of the general public during the COVID-19 pandemic.

Methods

A cross-sectional study was conducted using an online questionnaire survey to determine the extent of public behavioral changes in Saudi Arabia during the COVID-19 pandemic. Data were collected with a self-reported survey, and analysis was conducted using Statistical Package for the Social Sciences version 26 (SPSS). A chi-square test was performed to determine the association among variables. A P ≤ 0.05 was considered statistically significant.

Results

Of 348 respondents, 244 (70.1%) were male, and 270 (77.6%) had a university degree. Approximately 48% used social media to seek COVID-19 information, and 36% (n = 124) avoided large gatherings. Approximately one-fourth of the respondents always avoided public transportation, while 65.8% reported avoiding traveling to infected areas. Of the participants, 33% always washed their hands, while 36% always used an alcohol-based sanitizer. There was a significant association between age group and employment status with respect to hand washing frequency (p < 0.05). There was also a significant association between age group (p < 0.0001) and employment status and wearing of face masks (p < 0.048).

Conclusion

This study highlights changes in the public's behaviors in Saudi Arabia during the COVID-19 pandemic for protection against the infection and reports acceptable preventative practices against COVID-19 in the Saudi community. Furthermore, continuous awareness of recommended protective measures for COVID-19 is still warranted.

Coronavirus Precautions: Experience of High Volume Liver Transplant Institute

BACKGROUND

To present the struggle of a high volume liver transplant center against coronavirus infectious disease-2019 pandemic.

METHODS

Between March 2020 and December 2020, the demographic and clinical data of staff and liver transplant candidates diagnosed with coronavirus infectious disease-2019 in our Liver Transplant Institute were prospectively analyzed.

RESULTS

First, 32 healthcare staff were diagnosed with coronavirus infectious disease-2019, and 6 of them were surgeons. Six staff were asymptomatic, while 24 staff had mild or moderate and 2 staff had severe coronavirus infectious disease-2019. All the staff recovered from the disease without any permanent sequela and returned to duty after 2 consecutive negative polymerase chain reaction results within 24-hour intervals. Second, during the preoperative investigation, 6 living liver donor candidates and 13 recipients were tested positive for coronavirus infectious disease-2019 (son = 6, unrelated = 3, cousin = 3, daughter = 2, cadaveric = 1). Eleven patients received favipiravir and 8 did not receive any treatment because they were asymptomatic. Only one recipient who had severe coronavirus infectious disease-2019 died due to multiple organ failure syndrome. One recipient died in the early postoperative period. The median duration from the initial diagnosis of the patients till the transplant procedure was 21 days (min-max: 14-105 days). During the time of operation, the polymerase chain reaction tests of the donors and the recipients were negative, and the thorax tomography images showed no signs of viral pneumonia.

CONCLUSION

Meticulous precautions, multidisciplinary approach, team effort, and organization of facilities can increase the quality of care of these patients in the coronavirus infectious disease-2019 era. Healthcare workers have shown tremendous effort and are the true heroes of this era.

An Epidemiological Study of COVID-19 Cases in Al-Leith, Saudi Arabia

Background and objective

Ever since the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first detected in December 2019, more than 0.550 million cases of coronavirus disease 2019 (COVID-19) have been reported in the kingdom of Saudi Arabia (KSA) and the number is on the rise. In this study, we aimed to perform an epidemiological analysis of COVID-19 cases in Al-Leith, KSA.

Methods

A community-based descriptive study was carried out to assess the epidemiology of COVID-19 in Al-Leith, KSA. The relevant data were collected using a questionnaire designed for this study, which included questions on basic information and characteristics in addition to data on COVID-19. Data were analyzed using the SPSS Statistics software (IBM, Armonk, NY).

Results

The significant findings were as follows: people aged between 26-40 years were more affected (55.7%) than other age groups, and more than half (74.1%) of COVID-19 patients were female; most of them were employed (85, 48,9%), and most of those got infected through direct contact (137, 78.7%) with other infected people. About 163 (93.7%) cases were asymptomatic, and 168 (96.6%) cases were notified to the health authorities. The findings also illustrated that 78 (44.8%) COVID-19 cases suffered from psychological impact due to infection; 83 (47.7%) cases had at least one case in the family before they became infected. The majority of cases (93.7%) suffered from symptomatic COVID-19. A considerable number of COVID-19 patients did not follow precautions before and after infection.

Conclusions

The study concluded that various age groups were susceptible to developing COVID-19, and direct contact was the main mode of transmission. Moreover, a considerable number of infected people did not adhere to precautionary measures.

Predictors of poor precautionary practices towards COVID-19 among cancer patients

Objective: Our study goal was to evaluate the behavioral response and practices of cancer patients to the coronavirus disease 2019 (COVID-19) pandemic in the Middle East and north Africa. Methods: A cross-sectional study was conducted using a validated anonymous 45-question survey administered via SurveyMonkey^® to cancer patients in 13 centers in Algeria, Egypt, Jordan, Kuwait, Morocco and Saudi Arabia. Results: During the study period (from 21 April to 30 May 2020), 3642 patients participated in the study. The majority of patients (84.81%) were worried about contracting the infection. The reported strict adherence to precautions included avoiding the following actions: hand-shaking (77.40%), hugging and kissing (82.89%), social gathering (90.09%), meeting friends (84.68%) and visiting markets (75.65%). In a multivariate analysis, patients with poor precautionary practices were about twice as likely to cancel their medical appointment or a treatment session. Conclusion: Improving cancer patients' knowledge of and adherence to precautionary measures is needed not just to reduce the risk of acquiring infection but also to minimize the interruption of their medical care.

Measles vaccination of special risk groups

Measles is an important vaccine preventable disease with significant morbidity and mortality. Although measles vaccine is a safe and effective vaccine available worldwide for more than 50 years, still immunization efforts have not successfully reached the WHO goal of 95% vaccination coverage. Hesitancy is especially increased amongst parents of children with chronic conditions. Contraindications for measles-containing vaccines are well defined and include history of anaphylactic reactions to neomycin, history of severe allergic reaction to previous vaccination, pregnancy, and severe immunosuppression. Concurrently, precautions for measles-containing vaccines include amongst other, history of thrombocytopenia or thrombocytopenic purpura and personal or family history of seizures of any etiology. This article aims to address misconceptions on measles vaccine safety and review data on adverse events among special groups of subjects at increased risk following measles immunization.

Procedural Dermatology during COVID-19 Pandemic

The Corona virus disease of 2019 (COVID-19) pandemic has imposed unprecedented challenges on the healthcare system including the specialty of dermatology. Procedural dermatology being an integral part of the specialty has also been profoundly affected where all elective and cosmetic procedures are presently being deferred, giving priority only to urgent and inescapable dermatologic procedures to curb down the risk of SARS-CoV-2 transmission in hospitals. With no certainty as to when the pandemic is going to end, procedural dermatology will be resumed in times to come, which must be taken up with cautious precautions. Dermatosurgeons must formulate protocols, restructure their facilities, and implement stringent measures with the aim to limit the spread of SARS-CoV-2, providing, at the same time, essential surgical care to patients. This review highlights the salient precautions to be observed in a dermatosurgery facility based on the current recommendations. The situation, however, remains fluid and as the pandemic is evolving, dermatosurgeons should remain vigilant and acquaint themselves with the latest guidelines.

The Prevalence and Clinical Features of Skin Irritation Caused by Infection Prevention Measures During COVID-19 in the Mecca Region, Saudi Arabia

PURPOSE

Due to the COVID-19 pandemic, recommendations to prevent infection suggest increasing the frequency of handwashing and disinfection; however, these measures can have negative implications on our skin. This study aims to evaluate whether these measures correlate with new-onset skin damage or can exacerbate hand eczema among the general population.

MATERIALS AND METHODS

This was a descriptive, cross-sectional, survey-based study, including the general population of Mecca region, Saudi Arabia. To achieve the study's aim, an online questionnaire to the general population comprising 25 items was distributed via social media apps during the pandemic between October 23 and November 21, 2020. Data were automatically collected in Excel and entered into SPSS for analysis.

RESULTS

A total of 783 participants were included in this study, of whom 695 (88.8%) were female. A history of hand eczema was reported among 123 (15.7%) participants, and 270 (34.5%) had a history of atopy. During the COVID-19 pandemic, 86 (13.0%) participants noticed new-onset skin irritation, while 81 (31.3%) of the participants reported exacerbation of earlier hand allergic dermatitis. The most frequent symptoms were dryness and feeling of tightness. Additionally, most participants among both groups noticed that skin lesions appeared for less than 10 days. The frequent handwashing statistically increased following the onset of the pandemic (p=0.001), there is association between new-onset symptoms and more frequent handwashing, as well as the use of hand disinfectants, during the pandemic (p=0.001).

CONCLUSION

Our study suggests that the general population's skin was negatively affected by COVID-19 precautions, particularly those with a history of hand eczema. We recommend spreading awareness of skin protective modalities and the use of new infection prevention measures, such as regular skin moisturization for hand protection and possibly using less damaging skin disinfectants like ozonized water provided it is scientifically proven effective in disinfecting COVID-19 virus.

The 'new normal' in post-COVID-19 pediatric dental practice

The COVID-19 pandemic has posed an extraordinary challenge to the world. Dental healthcare personnel are considered to be at high risk as they work in close proximity to the oral cavity of patients. New procedures of approach and management should be incorporated in different aspects of routine dental practice. In addition, pediatric dentists are posed with unique and extraordinary challenges of parental anxiety and behavioral guidance of pediatric patients and parents/guardians. The aim of this study was to highlight the changing perceptions of pediatric dental practice as the 'new normal' in the post-COVID era.

Factors Influencing Emergency Department Nurses' Compliance with Standard Precautions Using Multilevel Analysis

Standard precautions protect patients and nurses from infection. Nevertheless, compliance with standard precautions is lower among emergency department nurses than other nurses. We examined the individual and organizational factors that influence emergency department nurses’ compliance with standard precautions via a cross-sectional study. A self-reported questionnaire survey was administered to 140 nurses working in nine emergency departments in South Korea. It included items regarding ethical awareness and standard precaution self-efficacy at the individual level as well as safety environment, organizational culture for infection control, and degree of compliance with standard precautions at the organizational level. Individual and organizational predictors were identified using a multilevel analysis. The results indicated that 81.1% of nurses’ compliance with standard precautions was influenced by individual differences, while only 18.9% was influenced by organizational differences. Individual- and organizational-level predictors explained 46.7% and 55.4% of the variance in emergency department nurses’ compliance with standard precautions, respectively. Emergency department nurses’ compliance with standard precautions was predicted by ethical awareness and standard precaution self-efficacy at the individual level and by organizational culture for infection control at the organizational level. Our findings provide evidence for the need to improve facilities and human resource management as well as the organizational culture for infection control.

COVID-19 Health Precautions: Identifying Demographic and Socio-Economic Disparities and Changes over Time

The recent coronavirus disease 2019 (COVID-19) pandemic has required the adoption of precautionary health behaviours to reduce the risk of infection. This study examines adherence, as well as changes in adherence, to four key precautionary behaviours among Canadian adults: wearing face masks, social distancing, hand washing, and avoiding large crowds. Data are drawn from Series 3 and 4 of the nationally representative Canadian Perspectives Survey Series, administered by Statistics Canada in June and July 2020. We calculate overall adherence levels as well as changes over time. Logistic regression models estimate each behaviour as a function of demographic and socio-economic characteristics to identify adherence disparities across population segments. We find a nearly universal increase in precautionary behaviours from June to July in mask wearing (67.3 percent to 83.6 percent), social distancing (82.4 percent to 89.2 percent), and avoiding crowds (84.1 percent to 88.9 percent); no significant change occurred in the frequency of hand washing. We observe significant disparities in adherence to precautionary behaviours, especially for mask wearing, in June; female, older, immigrant, urban, and highly educated adults were significantly more likely to adhere to precautionary behaviours than male, younger, Canadian-born, rural, and low-educated adults. By July 2020, these disparities persisted or were slightly attenuated; women, however, had consistently higher adherence to all behaviours at both time points. These findings have substantial implications for policy and potential public health interventions.

Awareness and experience of health-care workers during coronavirus disease 2019 pandemic

BACKGROUND

During the 2nd week of July 2020, the coronavirus disease 2019 (COVID 19) infection spreading in the community. Now more than 15 lakhs peoples have been infected in India, out of the 26816 patients were deceased. COVID 19 outbreaks become an additional hazard to the health-care workers (HCWs), leading to fatigue, anxiety, depression and fear of death. The objective of this questionnaire-based study is to know about the knowledge of HCWs about COVID 19, their experiences while dealing with the disease, and the protective measures taken to prevent the infection.

MATERIALS AND METHODS

A cross-sectional, questionnaire-based study was conducted for 1 month starting from the 2nd week of June 2020 after getting institutional ethical clearance. This study included 240 HCWs posted in the medical and surgical Departments of All India Institute of Medical Sciences, Jodhpur, Rajasthan. This questionnaire was prepared in online Google forms and required 2 min to complete. Mean, median, range, and standard deviation were used to describe the continuous variables, and percentages were used to describe the categorical data.

RESULTS

Among 240 HCWs, 79.16% (n = 190) participants have good knowledge and adapted good precautions (score 15-23) for COVID 19 infection. Rest 20% (n = 48) and 0.8% (n = 2) participants has average (score 8-14) or poor knowledge (score <8) with adaptation of average or poor precautionary measures against COVID 19, respectively.

CONCLUSION

This study concluded that we have the requirement of more educational training programs for awareness of HCWs and precautionary measures against COVID 19. Thereby, HCWs can improve their knowledge and participate in this fight against COVID 19 with more efficiency and confidence.

Teratogenic Genesis in Fetal Malformations

Congenital anomalies can occur during the developmental stages of the embryo, from abnormal genetics passed on from the parents or from vivid environmental factors. While advanced technologies are able to detect chromosomal abnormalities, there are many unknown non-genetic variants. Teratogenic factors pose a greater risk to the fetus, as these abnormalities may go undetected until birth. These malformations are the origin of the infant's postnatal illness and disability. The defects can also lead to mortality. The loss can also affect families, as they are affected by not only the loss but also financially. Most of the teratogenic-induced anomalies, once detected, maybe rehabilitated naturally. Those who do require medical intervention pose their own risks, similar to those of infections. Therefore, environmental exposure to teratogens can create long-lasting effects that range from infertility, intrauterine growth restriction, structural defects, and functional central nervous system abnormalities that may lead to fetal death.

Reopening the country: Recommendations for nuclear medicine departments

The best practices for nuclear medicine departments to operate safely during the COVID-19 pandemic have been debated in the literature recently. However, as many governments have started to ease restrictions in activity due to COVID-19, a set of guidelines is needed to resume routine patient care throughout the world. The nonessential or elective procedures which were previously postponed or canceled during the COVID-19 pandemic will gradually restart in the following weeks despite the continued risks. In this paper, we aim to review some of the most effective general precautions to restart the regular nuclear medicine operations safely.

Clinical deterioration and hospital-acquired complications in adult patients with isolation precautions for infection control: A systematic review

AIM

To review and synthesize literature examining clinical deterioration and hospital-acquired complications in adult patients with isolation precautions for infection control.

BACKGROUND

Isolation precautions are a common infection prevention and control strategy which may have impact on safety and quality of care.

DESIGN

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines guided this systematic review, which was registered with PROSPERO [CRD42019131573].

DATA SOURCES

A search of Medline, Embase, and Cumulative Index to Nursing and Allied Health Literature was conducted for studies published in English up to 5 April 2019.

REVIEW METHODS

Risk of bias was determined using Critical Appraisal Skills Program tools. Quality appraisal was performed using the Grades of Recommendation, Assessment, Development, and Evaluation approach. The primary outcomes of interest were clinical deterioration events and hospital-acquired complications. In-hospital death and hospital length of stay were secondary outcomes. Data were synthesized using a narrative approach.

RESULTS

The search yielded 785 citations after removal of duplicates, of which, six studies were relevant. Certainty of evidence for outcomes of interest was low to very low.

CONCLUSION

There is no strong evidence that adult medical and surgical ward patients in isolation precautions for infection control are more or less likely to experience clinical deterioration or hospital-acquired complications.

IMPACT

What problem did the study address? Are patients in isolation precautions more likely to experience clinical deterioration or hospital-acquired complications than non-isolated patients? What were the main findings? There is no strong evidence that clinical deterioration and hospital-acquired complications are more likely to occur to patients in isolation precautions for infection control. This research is of relevance to acute care nurses.

Joint IFS-ISAR-ACE Recommendations on Resuming/Opening up Assisted Reproductive Technology Services

COVID-19 – A Global challenge on a scale not previously seen. Reproductive care is essential for the well-being of society and therefore the treatment needs to be completely re-thought and individualised. Infectivity and mortality rates are higher than previous pandemics and the disease is present in almost every country. Propagation and containment have varied widely by location and, at present, the timeline to complete resolution is unknown. With successful mitigation strategies in some areas and emergence of additional data, the societies have sanctioned gradual and judicious resumption of delivery of full reproductive care. When we resume, monitor local conditions, including prevalence of disease, status of government or state regulations, and availability of resource. It is important to implement proactive risk assessment within their practices prior to restarting services. One needs to develop clear and modified plans to ensure the ability to provide care while maximizing the safety of their patients and staff. One should also remain informed and stay current regarding new medical findings. These recommendations provide resources for restarting ART practice again.

Respiratory droplet generation and dispersal during nasoendoscopy and upper respiratory swab testing

Respiratory particle generation and dispersal during nasoendoscopy and swab testing is studied with high‐speed video and laser light illumination. Video analysis reveals droplet formation in three manoeuvres during nasoendoscopy ‐ sneezing, vocalization, and nasal decongestion spray. A capillary bridge of mucus can be seen when a nasoendoscope exits wet nares. No droplet formation is seen during oral and nasopharyngeal swab testing. We outline the following recommendations: pull the face mask down partially and keep the mouth covered, only allowing nasal access during nasoendoscopy; avoid nasal sprays if possible; if nasal sprays are used, procedurists should be in full personal protective equipment prior to using the spray; withdrawal of swabs and scopes should be performed in a slow and controlled fashion to reduce potential dispersion of droplets when the capillary bridge of mucus breaks up.

All India Ophthalmological Society - Eye Bank Association of India consensus statement on guidelines for cornea and eyebanking during COVID-19 era

The COVID-19 pandemic has brought with it the huge burden of mortality and morbidity across the world and the added effects of the mandatory lockdown measures to try and control the spread. A number of aspects of healthcare including eye donation and eye collection require adequate safety precautions in place to keep both the involved healthcare workers and patients safe. This paper highlights the consensus-based guidelines by an expert panel on how to restart eye banking and eye collection services and carry out emergency corneal surgeries during this COVID-19 time. These guidelines will be applicable to all eye banks across the country and should help ophthalmologists and eye banking staff to restart eye banking while safeguarding themselves and their patients.

Potential ocular and systemic COVID-19 prophylaxis approaches for healthcare professionals

The COVID-19 pandemic has brought with it, innumerable challenges in healthcare, both through the direct burden of morbidity and mortality of the disease, and also by the curtailing of other essential albeit less emergency medical services to reduce the risk of community spread. Reports from around the world are showing mounting number of cases even in healthcare professionals spite of usage of adequate personal protective equipment. There are a number of factors which could account for this, be it the affinity of the virus to the respiratory and other mucosa or to patient risk factors for developing severe forms of the disease. In view of the growing need for resuming other medical services, it is essential to find newer ways to protect ourselves better, whether by systemic or topical mucosal prophylaxis with various medications or lifestyle changes promoting wellbeing and immunity. This article discusses additional prophylactic measures including drug repurposing or new indication paradigms to render protection. Certain medications such as chloroquine, trehalose, antihistaminics, and interferons used topically for various ocular conditions with reasonably good safety records are known to have anti-viral properties. Hence, can be harnessed in preventing SARS-CoV-2 attachment, entry, and/or replication in host cells. Similarly, use of hypertonic saline for nasal and oral mucosa and dietary changes are possible methods of improving our resistance. These additional prophylactic measures can be cautiously explored by healthcare professionals to protect themselves and their patients.

[The War Against the Coronavirus Disease (COVID-2019): Keys to Successfully Defending Taiwan]

The outbreak of COVID-19 triggered the largest human-virus war in this century. Current evidence indicates that the SARS-CoV-2 strain of coronavirus is mainly transmitted by droplets either by direct or indirect contact. The duration of infectiousness of COVID-19 ranges from 1-2 days before and 7-10 days after the onset of symptoms. It is often difficult to detect the signs and symptoms of infection and to implement timely intervention during the very early stage of infection. Thus, finding and isolating symptomatic patients may not be sufficient to contain this epidemic. Therefore, it is very important to wear masks, take personal precautions, and practice recommended social distancing to achieve source control and stop transmission. Taiwan has learned from its previous experience with the SARS epidemic and prepared for the potential of new disease outbreaks for at least 17 years. This helped the government to implement a multifaceted strategy in the early stages of the COVID-19 outbreak. Taiwan's effective response has made the country a model for pandemic response policy that has been appreciated internationally. This paper examines COVID-19 epidemic prevention from the perspective of infection control strategies. In Taiwan, hospital infection control, which is practiced nationwide, emphasizes the importance to epidemic prevention of collecting and tracking travel history, occupation, contact history, cluster (TOCC) information; practicing hand hygiene; promoting the correct use of personal protective equipment; and maintaining safe distances from others. Personal control measures are recognized as critical to providing a safe environment for patients and staff.

All India Ophthalmological Society - Oculoplastics Association of India consensus statement on preferred practices in oculoplasty and lacrimal surgery during the COVID-19 pandemic

Oculoplastic surgeries encompass both emergency surgeries for traumatic conditions and infectious disorders as well as elective aesthetic procedures. The COVID-19 pandemic has brought about a drastic change in this practice. Given the highly infectious nature of the disease as well as the global scarcity of medical resources; it is only prudent to treat only emergent conditions during the pandemic as we incorporate evidence-based screening and protective measures into our practices. This manuscript is a compilation of evidence-based guidelines for surgical procedures that oculoplastic surgeons can employ during the COVID-19 pandemic. These guidelines also serve as the basic framework upon which further recommendations may be based on in the future, as elective surgeries start being performed on a regular basis.

All India Ophthalmological Society - Indian Journal of Ophthalmology consensus statement on preferred practices during the COVID-19 pandemic

The COVID-19 pandemic has taken tragic proportions and has disrupted lives globally. In the wake of governmental lockdowns, ophthalmologists need practical and actionable guidelines based on advisories from national health departments on how to conduct their duties during nationwide lockdowns and after these are lifted. In this paper, we present a preferred practice pattern (PPP) based on consensus discussions between leading ophthalmologists and health care professionals in India including representatives from major governmental and private institutions as well as the All India Ophthalmological Society leadership. In this document, the expert panel clearly defines the range of activities for Indian ophthalmologists during the ongoing lockdown phase and precautions to be taken once the lockdown is lifted. Guidelines for triage, governmental guidelines for use of personal protective equipment from ophthalmologists' point of view, precautions to be taken in the OPD and operating room as well as care of various ophthalmic equipment have been described in detail. These guidelines will be applicable to all practice settings including tertiary institutions, corporate and group practices and individual eye clinics and should help Indian ophthalmologists in performing their professional responsibilities without being foci of disease transmission.

Therapeutic potential of medicinal plants for the management of scabies

Sarcoptes scabiei (S. scabiei), a parasite mite which causes scabies disease resulting in serious public health concern. The long-term scabies disease can lead to complications such as septicemia, acute post-streptococcal glomerulonephritis, heart disease, and secondary infections. Timely treatment to the affected patients is required to control the disease and get rid of the causative agent. Delayed diagnosis and inappropriate treatment can lead to serious consequences. The most common treatment strategy is the use of allopathic medicines which can immediately relieve the patient but have the drawback of side effects. The safe and cost-effective alternative treatment strategy is the use of medicinal plants which have beneficial therapeutic potential against variety of diseases due to the presence of many bioactive phytoconstituents with no or minimal side effects. For the present review, the published articles describing scabies disease and its phytotherapeutic modalities were searched through different data bases including Google Scholar, PubMed, Medline, and ScienceDirect using the keywords like S. scabiei, prevalence of scabies disease, and phytotherapy of scabies. A large number of medicinal plants, such as Melaleuca alternifolia, Curcuma longa, Azadirachta indica, Rosmarinus officinalis, Capsicum annuum, Cinnamomum camphor, Solanum nigrum, and Eupatorium perfoliatum, have been reviewed for the promising future treatments of scabies. All the studied plants have many bioactive compounds with potential therapeutic effects against scabies and can be utilized for therapeutic purposes for this disease. This literature study has limitations because of the lack of sufficient data due to limited pre-clinical trials in this particular area. This review provides a baseline to explore the therapeutic potential of these medicinal plants against skin diseases. However, extensive studies are required to identify, authenticate, and characterize the bioactive compounds present in these plants which may lead to value addition in pharmaceutical industries providing the cost-effective way of treatment with minimal side effects.

Less Postoperative Restrictions Following Total Hip Arthroplasty With Use of a Posterolateral Approach: A Prospective, Randomized, Noninferiority Trial

BACKGROUND

Patient restrictions are prescribed after total hip arthroplasty (THA) to ensure proper healing and prevent early dislocation. It has been suggested that less or nonrestrictive protocols following THA do not lead to higher dislocation rates. Nonetheless, restrictions are still widely used. The aim of this study is to evaluate the rate of early dislocations when patients were restricted to supine sleeping or unrestricted sleeping in the first 8 weeks after THA using a posterolateral approach.

METHODS

The study design was a single-center, parallel-group, stratified, randomized, noninferiority trial in which primary THA patients were allocated to either a restricted group or a nonrestricted group. The primary outcome was early (<8 weeks) dislocation rate. Secondary outcomes include pain (visual analog scale [VAS]), function in activities of daily living (Hip Disability and Osteoarthritis Outcome Score [HOOS]), and quality of life (EuroQoL 5 Dimension [EQ-5D]).

RESULTS

A total of 408 patients were randomized into 2 groups: those who were restricted in their sleeping position (n = 203) and those who received no restrictions in sleeping position (n = 205). Three patients (1.48%) from the restricted group and 3 patients (1.46%) from the unrestricted group had a dislocation. The noninferiority of the restricted group compared to the nonrestricted group was established for early dislocation. In addition, no statistically significant differences were found for VAS, HOOS, and QoL-5D between both groups. Both groups showed a significant improvement in VAS, HOOS, and QoL-5D.

CONCLUSION

Early dislocation rates in patients who were advised to comply to an unrestricted sleeping position following THA were not inferior to the dislocation rates in patients who were advised to sleep in a supine position following THA. The results of the present study strengthen the discussion regarding the relevance of providing patients with restrictions following THA.

Post-discharge use of assistive devices following hemiarthroplasty: comparison of fracture patients with or without hip precautions

Purpose: To describe which types of assistive devices prescribed and actually used, either due to precautions or due to true functional reasons, after hip fracture-related hemiarthroplasty.Materials and methods: About 394 patients cluster-randomized 2010-2014 at a university hospital. Control group with standard postoperative precautions to reduce dislocations, mandatory assistive devices and knee brace for 6 weeks (in cognitively impaired) compared to non-precaution group with assistive devices only if needed. Postal questionnaire at 6 weeks and 3 months.Results: Both prescription and usage of reacher were higher in the precaution group. About 55% of patients with precautions was instructed to use stocking aids, 21% continued to do so. Significantly fewer without precautions, 11%, used it at 3 months. Raised toilet seat was used by ∼40% of all pre-fracture and was prescribed to 79% with precautions. It was unchanged at 42% in non-precaution group. Nevertheless, 64% in non-precaution group used a raised toilet both at 6 weeks and 3 months. The usage persisted around 70% in precaution group. Usage of raised chair/bed were similar, even if non-precaution patients was not prescribed such. In the precaution group, 102 were prescribed a knee brace, only 5 used it at 6 weeks.Conclusions: The use of assistive devices did not follow what was prescribed from the hospital, regardless of precautions or not. The use of higher furniture was similar regardless of precautions or not. Other devices were more common in the precaution group. The compliance of knee bracing was low, and bracing should not be standard-of-care.Implications for rehabilitationHemiarthroplasty is the most common treatment of displaced femoral neck fracture in elderly. Dislocation occur in 2 to 10% of these patients, and traditionally patients have been instructed to be careful when moving their leg and to use a number of assistive devices, in order to reduce the dislocation risk.The evidence base for such precautions is weak and occupational therapy and assistive devices may be costly. The current study shows that prescriptions and instructions from occupational therapists in hospital is more or less not follow after dismissal.Assistive devices should be prescribed based on the hip fracture patient's true functional needs, and not routinely or due to arthroplasty precautions.

The effect of precautions on early dislocations post total hip arthroplasty: a retrospective cohort study

INTRODUCTION

The efficacy of hip precautions in preventing dislocation post total hip arthroplasty (THA) has been questioned in recent literature. From 2014 our centre ceased routinely prescribing them due to lack of evidence. We investigate the effect of stopping these precautions on dislocation rate, patient satisfaction and Oxford hip score (OHS).

METHODS

Patients who underwent primary total hip arthroplasty prior to this change in protocol ( n = 2551) and for 1 year subsequently ( n = 673) were identified. Operative records were used to identify key demographic and operative data. Incidence of dislocation, OHS and patient satisfaction were extracted from the centre's electronic database. Subset analysis of those patients dislocating within 6 weeks was performed.

RESULTS

Rate of dislocation at 6 weeks in those prescribed and not prescribed precautions was 0.71% and 0.89% respectively ( p = 0.618). At 1 year this rose to 1.25% and 1.49% ( p = 0.406). Satisfaction ( p = 0.332) and OHS ( p = 0.441) at 1 year was not significantly different between cohorts.

CONCLUSIONS

Cessation of prescribing routine hip precautions post primary THA does not appear to significantly affect overall dislocation rate, patient satisfaction or functional status at 1 year post-operatively.

Why, when and for what diseases pregnant and new mothers "should" be vaccinated

Immunological and serological changes that occur during pregnancy can alter the susceptibility of both the mother and the fetus against various infectious diseases. The pregnant woman has an altered immune response and, for some pathologies, is at increased risk of infection and of developing complications and serious outcomes. In addition, maternal infections can result in congenital anomalies, malformations or severe neonatal diseases. Vaccination of pregnant women can therefore have a double goal: to protect the mother from diseases that could have an impact on her health and to avoid infection/disease transmission to the fetus or the newborn. Despite the potential benefits of immunization in pregnant women, it is still evident reluctance and/or refusal of vaccinations by health professionals as well as by pregnant women, who are wary of the real advantages linked to vaccines. For these reasons a group of experts has evaluated the latest scientific evidence reported in the international literature on this relevant topic.

The Importance of Mammalogy, Infectious Disease Research, and Biosafety in the Field

Large amounts of data and multitudes of publications have been independently generated by researchers in mammalogy and infectious diseases. The frequent confluence of these fields in epidemiological research as well as the facility of the data generated to be used in applied methods (e.g., conservation, public outreach, public health interventions) suggests that the intersection of these fields is important not only to their committed scientists but also to other areas of investigation, including public health. Given the increased frequency with which researchers in these fields interact with potentially infected humans, animals, and tissues, their occupations present a higher risk of exposure to a variety of pathogens than those in other fields of biology or among most jobs of the general public. However, a variety of methods are available for minimizing this risk, including increasing awareness of potential risks, using medical prophylaxes (when available), properly employing personal protective equipment, and using adequate disinfectants. Although instances of serious illness from zoonotic diseases among field researchers may be uncommon, they do occur; the purpose of this document is to increase awareness of risks that researchers-principal investigators and students alike-face and highlight steps and resources that can mitigate those risks.

Precautions for the Prevention of Mine Accidents and Related Respiratory Emergencies

Mine accidents and related respiratory emergencies can be prevented. Employers and governments have responsibilities to protect employees from mine accident-associated respiratory emergencies. Effective ventilation in the mines, usage of new mining technologies, and education of employees are the primary routes. Use of the personal protective equipment is valid when general precautions are not adequate.

More Than Fear Induction: Toward an Understanding of People's Motivation to Be Well-Prepared for Emergencies in Flood-Prone Areas

This article examines the extent and manner to which evaluations of flood-related precautions are affected by an individual's motivation and perception of context. It argues that the relationship between risk perception and flood risk preparedness can be fruitfully specified in terms of vulnerability and efficacy if these concepts are put into the perspective of prevention-focused motivation. This relationship was empirically examined in a risk communication experiment in a delta area of the Netherlands (n = 1,887). Prevention-focused motivation was induced by contextualized risk information. The results showed that prevention-focused individuals were more sensitive to the relevance of potential precautions for satisfying their needs in the context they found themselves in. The needs included, but were not limited to, fear reduction. Due to the heterogeneity of the residents, the evaluations reflected individual differences in the intensity and the selectivity of precautionary processes. Four types of persons could be distinguished according to their evaluation of precautionary measures: a high-scoring minority, two more selective types, and a low-scoring minority. For policymakers and risk communicators it is vital to consider the nature of prevention motivation and the context in which it is likely to be high.

Trust in Nanotechnology? On Trust as Analytical Tool in Social Research on Emerging Technologies

Trust has become an important aspect of evaluating the relationship between lay public and technology implementation. Experiences have shown that a focus on trust provides a richer understanding of reasons for backlashes of technology in society than a mere focus of public understanding of risks and science communication. Therefore, trust is also widely used as a key concept for understanding and predicting trust or distrust in emerging technologies. But whereas trust broadens the scope for understanding established technologies with well-defined questions and controversies, it easily fails to do so with emerging technologies, where there are no shared questions, a lack of public familiarity with the technology in question, and a restricted understanding amongst social researchers as to where distrust is likely to arise and how and under which form the technology will actually be implemented. Rather contrary, 'trust' might sometimes even direct social research into fixed structures that makes it even more difficult for social research to provide socially robust knowledge. This article therefore suggests that if trust is to maintain its important role in evaluating emerging technologies, the approach has to be widened and initially focus not on people's motivations for trust, but rather the object of trust it self, as to predicting how and where distrust might appear, how the object is established as an object of trust, and how it is established in relation with the public.

Medical and health economic evaluation of prevention- and control measures related to MRSA infections or -colonisations at hospitals

Introduction

Methicillin-resistant Staphylococcus aureus (MRSA) are dangerous agents of nosocomial infections. In 2007 the prevalence of MRSA is 20.3% in Germany (Oxacilline-resistance according to EUCAST-criteria [EUCAST = European Committee on Antimicrobial Susceptibility Testing]).

Objectives

Which measurements are effective in the prevention and control of MRSA-infections in the hospital?

How effective are contact precautions, screening, decolonisation, education and surveillance?

Which recommendations can be given to health care politics on the basis of cost-effectiveness studies?

Have there been any adverse effects on patients and clinical staff?

What kind of liability problems exist?

Methods

Based on a systematic review of the literature studies are included which have been published in German or English language since 2004.

Results

1,508 articles have been found. After having surveyed the full text, 33 medical, eight economic and four ethical/juridical studies are included for the Health Technology Assessment (HTA) report.

The key result of the HTA report is that different measurements are effective in the prevention and control of MRSA-infections in hospitals, though the majority of the studies has a low quality. Effective are the conduction of differentiated screening measurements if they take into account the specific endemic situation, the use of antibiotic-control programs and the introduction and control of hygienic measurements. The break even point of preventive and control measurements cannot be defined because the study results differ too much. In the future it has to be more considered that MRSA-infections and contact precautions lead to a psycho-social strain for patients.

Discussion

It is hardly possible to describe causal efficacies because in the majority of the studies confounders are not sufficiently considered. In many cases bundles of measurements have been established but not analyzed individually. The internal and external validity of the studies is too weak to evaluate single interventions. Hygienic measurements prove to be effective in combination with other measurements. But it cannot be said which of the single measurements (gloves, washing hands, wearing gowns or masks) has the strongest effect on the reduction of MRSA. It is irritating that there are high differences in the compliance concerning hand hygiene between different studies. A general decolonisation is questionable for different reasons: first because of the side-effects for patients, second because of the high rate of spontaneous remissions in the untreated control group, third because of the differentiated process from colonisation to infection. Severalfold Hawthorne effects have been reported. One of them is that the competition between hospitals to reduce MRSA-rates leads already to a reduction.

Conclusions

It is evident that selective screening programs of risk patients considering the particular MRSA-prevalence are of use. The application of rapid tests seems to be only recommendable for risk patients and a high MRSA-prevalence. The improvement of the compliance of hand hygiene should be the basis of any prevention strategy. Training of staff members (with feedback mechanisms) is effective to improve compliance and to optimise the use of antibiotics. Antibiotic management programs are effective as well. Obviously multimodal approaches can lead to overadditive effects. Therefore the catalogue of preventive and control measurements has to be further evaluated. Good cost-efficacy studies are missing in Germany. The psychosocial effects of MRSA-infections are not researched in Germany. There is only punctual information on the risk management of hospitals.

Treating rheumatic diseases in pregnancy: dos and don'ts

This paper presents a critical appraisal of the current evidence and recommendations regarding the use of pharmaceuticals and biologicals in pregnancy. Clinical experience is often at variance with published recommendations as studies have not taken into account the differences in physiology in the various stages of gestation and between animal and human pregnancies. Physicians should bear in mind that pregnancy causes disruption in several organ systems; the effects of an intervention may depend on the stage of gestation; and some effects of interventions in pregnancy may not manifest until adulthood.