Clinics and Practice

Situations often arise in intensive care units (ICUs) for which only sparse primary evidence or guidelines are applicable or to which existing evidence cannot be applied owing to interactions of multiple disease states. To improve and guide intensive care management in complex scenarios, ultrasonography and echocardiography are invaluable. In five clinical scenarios involving acute deterioration, serial ultrasound examinations of the respiratory system, general critical care ultrasound (GCCUS), and non-invasive haemodynamic critical care echocardiography (CCE) were used routinely. Ultrasonographic results were used to guide further management and initiate experimental therapy or transition from curative to supportive care. The process of initiation of ultrasound examinations to clinical decision-making in these complex scenarios is outlined. These case vignettes highlight the utility of ultrasound and echocardiography. When clinical management is not clear, or evidence is not available, the use of ultrasound for the evaluation of the respiratory system, GCCUS, and non-invasive haemodynamic CCE can help to guide management, reveal newly developed pathologies, lead to clinical management changes, and support the decision for employing experimental therapy approaches in a dynamic way of which few other imaging modalities or monitoring tools are currently capable. Full article

Cancer is the third-leading cause of death in the United Arab Emirates (UAE); cancer care in the UAE has evolved dramatically over the last 40 years, from a single center in Al Ain in 1981 to more than 30 cancer centers and clinics across the UAE, with at least four comprehensive cancer centers in the UAE nowadays. Despite the significant progress in medical care, cancer quality control across the UAE is still lacking, with significant variations in cancer care across the cancer centers. Access to clinical trials is still hampered by a lack of expertise and research infrastructure and a small population, which renders patient accrual for trials a major challenge. Education and training are other areas for improvement that require immediate attention, and, in this review, we try to address these critical aspects for stakeholders to consider better cancer care in the UAE. Early cancer detection and screening are still evolving in the UAE, and a national screening program is lacking. There is also a need to address barriers to screening and to consider less invasive screening methods such as approved blood-based screening, which is likely to be more acceptable to the UAE population. In this review, we also address new topics that have not been addressed previously, including oncology medical tourism, psycho-oncology, onco-fertility, precision oncology, survivorship, oncology nursing, cancer support programs, and the oncology sector’s response to the COVID-19 pandemic, all in the context of the UAE cancer landscape. Finally, we provide recommendations for policymakers, regulators, payers, patient advocacy groups, and the UAE oncology community regarding the delivery and future planning of high-quality cancer care. These recommendations are aligned with the UAE government’s vision to reduce cancer mortality and provide high-quality healthcare for its citizens and residents. Full article

Background/Objectives: The association between the nutritional risk and mortality in Brazilians with COVID-19 is poorly documented. Therefore, this study, for the first time, aimed at investigating the length of stay in the ICU and the chance of dying in patients with suspected COVID-19, without and with nutritional risk. Subjects/Methods: This retrospective monocentric study enrolled adult, COVID-19-positive patients that were admitted to the ICU at a university hospital. Biochemical analysis and clinical data were collected from medical records and the nutritional risk was assessed according to the Modified-Nutrition Risk in the Critically Ill (mNUTRIC) score. The Cox model was used to assess the chance of mortality in the patients with and without nutritional risk. Results: Out of 71 patients, 63.3% were male and 52% were older (≥60 years). Although no differences were found between groups for the length of stay in ICU, C-reactive protein, alanine aminotransferase and aspartate aminotransferase concentrations, the mNUTRIC ≥ 5 group had higher D-dimer than the mNUTRIC < 5 group. Regarding ICU mortality, most patients (69.5%) in the mNUTRI ≥ 5 group died while in the mNUTRIC < 5 group 33.3% died (p = 0.0001). In addition, patients with mNUTRIC ≥ 5 had (HR: 2.04 [95% CI: 1.02–4.09], p = 0.04) a more likely chance of dying than patients in the mNUTRIC < 5 group, even that adjusted by BMI and D-dimer concentrations (HR: 2.18 [95% CI: 1.04–4.56], p = 0.03). Conclusion: In patients with COVID-19, an mNUTRIC ≥ 5 score at admission leads to a more likely chance of death even after controlling for confounding variables. Full article

Mediastinal lymph node assessment is a crucial step in non-small cell lung cancer staging. Positron emission tomography (PET) has been the gold standard for the assessment of mediastinal lymphadenopathy, though it has limited specificity. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is quick, accurate, and a less invasive method for obtaining a diagnostic sample in contrast to mediastinoscopy. We performed a retrospective chart analysis of 171 patients to assess the adequacy of tissue obtained by EBUS for diagnosis and molecular profiling as well as the assessment of staging and lymph node (LN) stations diagnostic yield, in correlation to PET scan and the operator’s level of experience. A significantly increased tissue adequacy was observed based on the operators’ experience, with the highest adequacy noted in trained Interventional Pulmonologist (IP) (100%), followed by >5 years of experience (93.33%), and 88.89% adequacy with <5 years of experience (p = 0.0019). PET-CT scan ¹⁸F-fluorodeoxyglucose (FDG) uptake in levels 1, 2, and 3 LN had a tissue adequacy of 76.67%, 54.64%, and 35.56%, respectively (p = 0.0009). EBUS bronchoscopy method could be used to achieve an accurate diagnosis, with IP-trained operators yielding the best results. There is no correlation with PET scan positivity, indicating that both PET and EBUS are complementary methods needed for staging. Full article

Background: Neurocytokines may upregulate or downregulate neuropathic pain. We hypothesized that dextrose (D-glucose) injections for therapeutic purposes (dextrose prolotherapy: DPT) in painful knee osteoarthritis (KOA) would favorably affect synovial-fluid neurocytokine concentrations. Methods: Twenty participants with grade IV symptomatic KOA received synovial-fluid aspiration followed by dextrose or simulated dextrose injections, followed by the reverse after one week. All participants then received open-label dextrose injections monthly for 6 months, with serial assessments of walking pain at 20 min for 9 months, as well as synovial-neurocytokine-concentration measurements (calcitonin gene-related peptide, substance P (SP), and neuropeptide Y (NPY)) at one week and three months. Results: Clinically important analgesia was observed at 20 min and for 9 months post dextrose injection. One -week synovial-fluid SP concentration rose by 111% (p = 0.028 within groups and p = 0.07 between groups) in the dextrose-injected knees compared to synovial-fluid aspiration only. Three-month synovial-fluid NPY concentration dropped substantially (65%; p < 0.001) after open-label dextrose injection in all knees. Conclusions: Prompt and medium-term analgesia after intra-articular dextrose injection in KOA was accompanied by potentially favorable changes in synovial-fluid neurocytokines SP and NPY, respectively, although these changes were isolated. Including neurocytokines in future assessments of DPT to elucidate mechanisms of action is recommended. Full article

Background: Malignant mixed corticomedullary adrenal tumors (MCMTs) are extremely rare, with limited cases reported in the literature. The pathophysiology of malignant MCMTs is not well understood; the most prevailing theories are that it is a composite tumor of embryologically derived mesodermal (adrenal cortex) and neural crest (medulla) origin, perpetuating as two distinct cell lines forming a singular mass. Clinical features and laboratory diagnosis are associated with hypersecretions of the adrenal cortex and medulla. Surgical resection is curative in an isolated tumor. We reviewed and compared cases in the literature highlighting the pathogenesis and genetics of benign and malignant MCMT. Methods: Comprehensive literature analysis was conducted on PubMed and all the cases of mixed corticomedullary adrenal tumor published in English were included. Results: Most patients were female (73.1%) with a median age of 49 in women and 50 in men. Surgery was performed in all patients, and in four patients with malignant disease, chemotherapy was used as well. Clinically, most patients presented with hypertension (69%) followed by Cushing syndrome (42%) and diabetes (19%). Tumors often produced cortisol (74%), catecholamines (50%), and adrenocorticotrophic hormone (ACTH) (38%), with lower incidence of aldosterone- (7%) or dopamine (4%)-producing tumors. Immunohistochemical staining of 96% of cases showed Chromogranin-A (73%) and Synaptophysin (62%), followed by Inhibin-α (50%), Melan-A (31%), and S-100 (23%). Of the reported four cases with malignant disease, three showed a Ki-67 index of 40–50% with one showing less than 5%. Conclusion: Mixed corticomedullary adrenal tumors rarely present as a malignant disease requiring chemotherapy. Most MCMTs confer a good prognosis and respond well to surgical resection, though their pathogenesis is largely up to speculation because of limited data. Current theories regarding MCMT pathogenesis should be investigated further with genetic testing. Future research on MCMT may provide ways to guide physician diagnosis and subsequent treatment for refractory cases. Full article

Menstrual irregularities during isotretinoin therapy, including amenorrhea, can cause a great deal of health-status uncertainty such as the possibility of pregnancy. This study aimed to evaluate the effects of isotretinoin treatment on the menstrual cycle. This cross-sectional study was conducted among females aged between 15–45 years taking isotretinoin for acne. Descriptive statistics were used in the form of frequencies and percentages to represent categorical variables. Pearson’s chi-squared test was performed to assess the relationship between some of the variables with menstrual irregularities. A logistic regression model was performed to assess the risk factors for developing menstrual irregularities during isotretinoin therapy. Of participants with a known regular menstrual cycle, 10.4% were found to have irregularity in their cycle after starting the drug (p < 0.001). Amenorrhea was the most commonly reported menstrual irregularity in isotretinoin-treated females. Our results showed that single females, those who took isotretinoin for 10–12 months and who were concurrently taking hormonal contraceptives all have a statistically significant higher risk of developing menstrual irregularities than others. In conclusion, we found that a statistically significant number of participants with a regular menstrual cycle pre-isotretinoin intake developed irregularity in their cycle after starting the drug. The mechanism of how isotretinoin influences female hormonal imbalances, thereby affecting menstrual irregularities is still poorly understood and needs to be clarified in further clinical studies. Full article

Taking into account the unpredictable evolution of uterine STUMP and leiomyosarcomas, there are no clearly established therapeutic protocols to date, the only certified treatment being total hysterectomy. We performed a 5-year retrospective study including cases of malignant tumors and those with uncertain malignant potential originating in the smooth muscle tissue of the uterine body. The clinical data, pathological aspects, and the immunohistochemical results were statistically analyzed using SPSS Statistics Version 26. The main associations of the p53 gene were identified with age, atypia, and the occurrence of metastases. The average number of CD8+ T cells correlated with the hormonal status of the patients, the presence of diabetes, and alteration of thyroid function, but also with the severity of the atypia. The therapeutic method was represented by total hysterectomy, and 30% of the patients with leiomyosarcoma also benefited from adjuvant chemotherapy. The average period until death was 25.66 months. The present study showed that the mutant expression of p53 could have a role in assessing the clinical evolution of patients, given the association with exitus and metastasis. In addition, the average number of CD8+ T cells corresponded to severe atypia, indicating the possibility of applying targeted immunotherapies in these cases. Full article

Cancer research and clinical trials are essential to improve cancer patients’ outcomes and advance the oncology field. The United Arab Emirates (UAE) has been lagging in cancer research with many barriers, including healthcare, institutional, regulatory, patient and community, the global oncology community, and the pharmaceutical industry. In this report, we try to address these challenges from our perspective. Making clinical trials accessible for cancer patients in the UAE requires a collaborative approach from all stakeholders and serious consideration for the greater cause to improve the patient’s outcome and contribute to the advancement of the cancer field worldwide. There has been significant support from the UAE government and the regulators in the UAE to facilitate and encourage research in general and cancer research in particular with recent initiatives and international collaborations. Private and public institutions must overcome their competitive moods and work together to strengthen the research network across the UAE and improve accrual for potential clinical trials. Public awareness and education must overcome long-standing perceptions about research and clinical trials in the UAE. The pharmaceutical industry must work closely with institutions across the UAE and support them in establishing accredited research programs and clinical trial units. The Emirates Oncology Society is establishing the Oncology Research Working Group to advocate and advance cancer research in the UAE. All stakeholders must be engaged to successfully implement impactful clinical trials in the UAE and the region. Full article

Background: Vitiligo is a common acquired hypopigmentation skin condition defined by an idiopathic, gradual, and restricted loss of melanin pigment from otherwise healthy-looking skin. The present study aims to evaluate the knowledge and perceptions of and attitudes toward vitiligo among the general population of Jazan Province, Saudi Arabia. Methods: An observational cross-sectional survey targeting adults of the Jazan region was conducted in 2022. The data were collected using an electronic questionnaire distributed through social media in the region. Statistical analysis was performed using the SPSS computer program. Knowledge and attitude scores were computed. Results: Most of the respondents (83.7%) had an adequate knowledge level of vitiligo, and almost half of the respondents (46.8%) had a positive attitude toward the disease. The majority of the respondents (84.5%) knew that vitiligo is not contagious. However, the majority of the participants (78.6%) did not know that vitiligo is an autoimmune disease. Most of the respondents (93.1%) do not avoid shaking hands with a vitiligo patient to prevent infection, accept food prepared by a vitiligo patient (69.4%), accept sharing a plate with a vitiligo patient (73.6%), and accept to be helped by a vitiligo patient (86.7%). However, about half of the participants (50.4%) refused to marry a person diagnosed with vitiligo. The knowledge of vitiligo in the study population was not correlated with any of the demographic characters, such as age, gender, education, or occupation (p > 0.05). The most important factors associated with good attitudes were male gender (COR = 1.92; 95% CI: 1.92–2.84; p = 0.001) and being aged over 50 years (COR = 3.06; 95% CI: 1.53–6.13; p = 0.002). Conclusions: The population in Jazan had a good level of knowledge of vitiligo and a positive attitude toward patients with vitiligo. Social media is the source of information for vitiligo for the majority of the study population. The good attitude toward patients with vitiligo was more prevalent in males and older people. More efforts are needed to improve the knowledge of and attitudes toward vitiligo. Full article

Thrombocytopenia is one of the complications in human immunodeficiency virus (HIV) patients. To improve the health outcomes of patients living with HIV, it is important to understand the prevalence and pattern of associated key clinical markers globally. This meta-analysis, therefore, aimed to estimate the pooled prevalence of and associated clinical marker of thrombocytopenia globally. Methodology: The meta-analysis was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All statistical analyses were conducted using Stata. Twelve full-text papers out of 454 were eligible for meta-analysis. Results: Among 6686 participants, overall pooled prevalence of thrombocytopenia was 10.90% (95% CI: 7.91, 13.88) I² = 93.62%. In addition, thrombocytopenia was more prevalent by 25.11% (95% CI: 13.33, 36.88) in patients with CD + T < 200 cells/μL, and less prevalent in patients with CD + T < 200 cells/μL 10.10% (95% CI: 7.37, 12.83), respectively. Conclusions and recommendations: This meta-analysis established the prevalence of thrombocytopenia among patients living with HIV, and that it may be more prevalent in patients with CD + T < 200 cells/μL indicating the necessity of routine screening for various haematological markers and a careful treatment plan for HIV patients. Full article

Artificial intelligence is dramatically transforming medical imaging. In Saudi Arabia, there are a lack of studies assessing the level of artificial intelligence use and reliably determining the perceived impact of artificial intelligence on the radiology workflow and the profession. We assessed the levels of artificial intelligence use among radiology trainees and correlated the perceived impact of artificial intelligence on the workflow and profession with the behavioral intention to use artificial intelligence. This cross-sectional study enrolled radiology trainees from Saudi Arabia, and a 5-part-structured questionnaire was disseminated. The items concerning the perceived impact of artificial intelligence on the radiology workflow conformed to the six-step standard workflow in radiology, which includes ordering and scheduling, protocoling and acquisition, image interpretation, reporting, communication, and billing. We included 98 participants. Few used artificial intelligence in routine practice (7%). The perceived impact of artificial intelligence on the radiology workflow was at a considerable level in all radiology workflow steps (range, 3.64–3.97 out of 5). Behavioral intention to use artificial intelligence was linearly correlated with the perceptions of its impact on the radiology workflow and on the profession (p < 0.001). Artificial intelligence is used at a low level in radiology. The perceived impact of artificial intelligence on radiology workflow and the profession is correlated to an increase in behavioral intention to use artificial intelligence. Thus, increasing awareness about the positive impact of artificial intelligence can improve its adoption. Full article

Methemoglobinemia is a rare blood disorder characterized by the oxidation of heme iron from ferrous (Fe²⁺) to ferric (Fe³⁺) state, which increases oxygen affinity and impairs oxygen release to the tissue causing hypoxia. It can be congenital or acquired; however, most cases are acquired and caused by exogenous substances such as medications, chemicals, and environmental substances. Phenazopyridine is an over-the-counter urinary analgesic medication commonly used for symptomatic relief of dysuria and has been reported to cause methemoglobinemia. However, only a handful of cases of phenazopyridine-induced methemoglobinemia have been reported. We present a case of an 89-year-old female who presented with severe hypoxia, shortness of breath, headache, nausea, and dizziness caused by phenazopyridine-induced methemoglobinemia. She was found to have a methemoglobin level of 21.5% and was treated with methylene blue, leading to a rapid improvement of her symptoms. She was taking one over-the-counter phenazopyridine 200 mg tablet three times daily for two weeks for her chronic dysuria. This case highlights the need to have a high index of suspicion of phenazopyridine-induced methemoglobinemia in a patient presenting with unexplained shortness of breath with a history of phenazopyridine use as it could lead to severe methemoglobinemia with hypoxia that could potentially be fatal if not promptly diagnosed. Full article

There is considerable interest in data analytics because of its value in informing decisions in healthcare. Data variables can be derived from routinely collected records or from primary studies. The level of detail for individual variables in quantitative studies is often disregarded. In this work, we aim to present the concept of a minimum dataset for any variable. The most basic level of data collection is the value of a variable. In addition, there may be an indicator of severity and a measure of duration or how long the value has been present. The time course defines how the values for a variable fluctuated over time. The validity or accuracy of the values for a variable is also important to avoid spurious findings. Finally, there may be additional modifiers which drastically change the impact of a variable. In conclusion, the minimum dataset is a framework which can be used for the purposes of study design and appraisal of studies. Not all data requires full consideration of the minimum dataset framework for each variable, but the framework may be important if more detailed results are desired. Full article

Uterine artery pseudoaneurysm (UAP) is a rare and potentially life-threatening vascular anomaly caused by inadequate sealing of a ruptured wall of a uterine artery. It mainly occurs after a traumatic lesion and can lead to delayed postpartum hemorrhage. We report a rare case of UAP after an uncomplicated vaginal delivery in a patient with a history of deep-infiltrating endometriosis. Selective coil embolization was successfully performed. UAPs should always be considered in cases of unexplained abdominal pain after surgery or childbirth with or without vaginal bleeding. Full article

Purpose: We investigated intraoperative OCT (iOCT)—guided epiretinal membrane (ERM) and internal limiting membrane (ILM) removal using a novel forceps with a laser-ablated tip surface; it was designed to help prevent indentation force, shear stress, or tractional trauma when grasping very fine membranes. Patients and Methods: This retrospective study included patients who underwent 23- and 25-gauge pars plana vitrectomy (PPV) for vitreoretinal interface disorders. ERM and ILM peeling was performed under guidance with microscope-integrated iOCT using novel ILM forceps with laser-ablated tip surfaces. These forceps were engineered to enhance friction when grasping tissue. Evaluation of ERM/ILM manipulation included postoperative slow-motion video analysis of the number of grasping attempts, initial ILM mobilization, and observed damage to retinal tissue. Results: ERM/ILM removal was successfully performed in all patients, with an average of four grasp actions to initial membrane mobilization (91%). Additional use of a diamond-dusted membrane scraper was used in two cases (9%). Mean best-recorded visual acuity (BRVA) logMAR improved from 0.5 ± 0.34 to 0.33 ± 0.36 (p = 0.05) and mean central retinal thickness (CRT) improved from 462 ± 146 µm to 359 ± 78 µm (p = 0.002). Postoperative iOCT video analysis demonstrated hyper-reflectivity of the inner retinal layers associated with retinal hemorrhage in five eyes (22%), but no grasping-related retinal breaks. Conclusions: The texturized surface on the tips of the ILM forceps were found to be helpful for mobilizing ILM edges from the retinal surface. iOCT-guided ERM surgery also allowed for improved intraoperative tissue visualization. We believe that these two technologies helped reduce both unnecessary surgical maneuvers and retinal damage. Full article

Background. Despite their benefits, dental implants may sometimes fail for a diversity of causes; the most common reasons of failure are infection and bone loss. Porphyromonas gingivalis (P. gingivalis) bacteria show a major role in peri-implantitis infection and dental implant failure. Methods. In this study, the prevalence of P. gingivalis isolated from the gingival crevicular fluid (GCF) of fifteen Iranian patients with implant failure (more than 1/3 of the implant length), who had average oral and dental hygiene and no antibiotic use for at least one month, was determined. Moreover, the antimicrobial effects of curcumin nanocrystals against isolated P. gingivalis were investigated. The collected samples from patients were transferred to a microbiology laboratory to culture. The presence of P. gingivalis in the culture media was confirmed using a trypsin reagent test. An isolate from a patient with the highest colony count was selected to evaluate the antibacterial effects of curcumin nanoparticles. The inhibition zone diameter, minimum inhibitory concentration (MIC), and minimum bactericidal concentration (MBC) were determined. Results. Out of fifteen patients, eight (53.33%) were positive for the presence of P. gingivalis. The results of the microbial tests showed that curcumin nanoparticles had an MIC of 6.25 µg/mL and an MBC of 12.5 µg/mL. Conclusions. The use of curcumin nanoparticles may control the bacterial infection around the implant. Full article

Ethical discourse on prognosis disclosure is not yet well established. The core of the problem continues to be the dilemma between the right of self-determination and non-maleficence of patients. The prognosis disclosure policy based on Kantian autonomy provides a good solution for the problem. The policy includes demand for strict truth telling and its compatibility with patients’ best interest. However, there remains a discrepancy between theory and practice, especially when prognosis is disclosed just prior to their death. Kantian theory of prognosis is supplemented by a moralistic perspective. The moralistic perspective places high importance on temporality and relationships with others, which all human beings inherently possess. From the moralistic viewpoint, decisions about prognosis disclosure at the final stages of life must be individualized in order to be authentically autonomous. The decision to disclose a prognosis or not can only be determined by the relationships fostered over time with patients. Full article