Primary Dysmenorrhea: Pathophysiology, Diagnosis, and Treatment Updates

Primary dysmenorrhea (PD) is a common, disregarded, underdiagnosed, and inadequately treated complaint of both young and adult females. It is characterized by painful cramps in the lower abdomen, which start shortly before or at the onset of menses and which could last for 3 days. In particular, PD negatively impacts the quality of life (QOL) of young females and is the main reason behind their absenteeism from school or work. It is suggested that increased intrauterine secretion of prostaglandins F2α and E2 are responsible for the pelvic pain associated with this disorder. Its associated symptoms are physical and/or psychological. Its physical symptoms include headache, lethargy, sleep disturbances, tender breasts, various body pains, disturbed appetite, nausea, vomiting, constipation or diarrhea, and increased urination, whereas its psychological symptoms include mood disturbances, such as anxiety, depression, and irritability. While its diagnosis is based on patients’ history, symptoms, and physical examination, its treatment aims to improve the QOL through the administration of nonsteroidal anti-inflammatory drugs, hormonal contraceptives, and/or the use of non-pharmacological aids (e.g., topical heat application and exercise). Patients must be monitored to measure their response to treatment, assess their adherence, observe potential side effects, and perform further investigations, if needed. © 2022 The Korean Academy of Family Medicin

Prevalence, risk factors, and management practices of primary dysmenorrhea among young females

Background: Primary dysmenorrhea (PD) is one of the most common gynecological conditions among young females, which has a significant negative impact on health-related quality of life and productivity. Despite its high prevalence, the evidence is limited regarding the management-seeking practices and its perceived effectiveness among females with PD. Methods: This is a cross-sectional study conducted among 550 female students in six universities across Lebanon. The prevalence of PD, associated risk factors, and management-seeking practices were assessed using a self-administered questionnaire. Results: The prevalence of PD was 80.9%. Most of the females with PD described their menstrual pain as moderate (56%) to severe (34.6%), which significantly affected their daily activities and studying ability (P < 0.001). The major risk factors associated with PD included heavy menstrual flow (adjusted odds ratio [AOR] = 10.28), family history of PD (AOR = 2.52), history of weight loss attempt (AOR = 2.05), and medical specialization (AOR = 1.663). Only 36.9% of females with PD sought formal medical advice. Most dysmenorrheic females (76.4%) received medications for the management of PD, and remarkably none of them took hormonal contraceptives. Drugs commonly used for PD were mefenamic acid (26.2%), ibuprofen (25%), and paracetamol (11.5%), which were administered when the pain started (58.2%). All medications were significantly effective in reducing the pain score (P = 0.001), and most NSAIDs were more potent than paracetamol in managing PD (P = 0.001). However, no significant difference in adverse effects among medications was revealed. Moreover, no superiority of any individual NSAID for pain relief was established. Nevertheless, mefenamic acid was associated with the lowest risk of abdominal pain (OR: 0.03, P = 0.005) and the highest risk of flank pain (OR = 12, P = 0.02). Conclusions: Suboptimal management of PD is practiced among university students in Lebanon. Therefore, health care providers should educate dysmenorrheic females to optimize the self-management support of PD. Furthermore, future research is required to investigate females’ misconceptions about hormonal contraceptives in the management of PD, aiming to raise awareness and correct misconceptions. © 2021, The Author(s)

Contrast media volume is significantly related to patient lung volume during CT pulmonary angiography when employing a patient-specific contrast protocol

Aim: The purpose of this study is to investigate the relationship between contrast media volume and patient lung volume when employing a patient-specific contrast media formula during pulmonary computed tomography angiography (CTA). Materials and methods: IRB approved this retrospective study. CTA of the pulmonary arteries was performed on 200 patients with suspected pulmonary embolism (PE). The contrast media volume (CMV) was calculted by employing a patient-specific contrast formula. Lung volume was quantified employing semi-automated lung software that calculated lung volumes (intellispace -Philips). The mean cross-sectional opacification profile of central and peripheral pulmonary arteries and veins were measured for each patient and arteriovenous contrast ratio (AVCR) calculated for each lung segment.&nbsp; Mean body mass index (BMI) and lung volume were quantified. Receiver operating (ROC) and visual grading characteristics (VGC) measured reader confidence in emboli detection and image quality respectively. Inter and intra-observer variations were investigated employing Cohen’s kappa methodology. Results: Results showed that the mean pulmonary arterial opacification of the main pulmonary circulation (343.88±73HU), right lung; upper (316.51±23HU), middle (312.5±39HU) and lower (315.23±65HU) lobes and left; upper (318.76±83HU), and lower (321.91±12HU) lobes. The mean venous opacification of all pulmonary veins was below 182±72HU. AVCR was observed at all anatomic locations (p&lt;0.0002) where this ratio was calculated. Moreover, larger volumes of contrast significantly correlated with larger lung volumes (r=0.89, p&lt;0.03) and radiation dose (p&lt;0.03). VGC and ROC analysis demonstrated increased area under the curve: 0.831 and 0.99 respectively (p&lt;0.02). Inter-observer variation was observed as excellent (κ = 0.71). Conclusion: We conclude that increased CMV is significantly correlated to increased patient lung volume and radiation dose when employing a patient-specific contrast formula. The effects patient habitus is highlighted

Imaging Modalities Employed in the TAVR Procedure With a Focus on CTA: What the Radiologist Needs to Know

Rationale and Objectives: Aortic stenosis (AS) is one of the most common valvular heart disease. Symptomatic AS is associated with a high mortality rate which prompts fast intervention. The introduction of transcatheter aortic valve replacement (TAVR) has drastically improved the outcome of high surgical risk for mortality patients with severe AS. However, this procedure requires the employment of multimodality imaging in the pre-procedural planning, intra-procedural optimization, and post-procedural follow-up stages. This also requires an accurate understanding of the indications, measurements, strength, and limitations of each imaging modality during the different TAVR stages. Conclusion: In this review, we aim to outline to radiologists the evidence-based approach and indications of different imaging modalities through the pre, peri, and post TAVR stages. © 2021 The Association of University Radiologist

Quantification of epi- and pericardial adipose tissue deposits between males and females during cardiac CT may potentially help categorize coronary artery disease risk with thoracic circumference

Introduction: This study aims to investigate the association between epi- and pericardial adipose tissue deposits around the heart against patient body habitus when using cardiac computed tomography (CT). Methods: Ninety-two consecutive patients with suspected coronary artery disease underwent coronary CT angiography with quantitative cardiac and adipose tissue volume measurements. Body mass index (BMI), body surface area (BSA), thoracic circumference, anteroposterior diameter, cardiac and adipose tissue volumes were compared between genders by employing Pearson's correlation and results were considered statistically significant if p ≤ 0.05. Results: Statistically significant differences between genders were observed with males having a greater height (males 1.72 ± 0.11), BMI (30.76 ± 7.87 kg/m2), BSA (2.06 ± 0.21 m2), thoracic circumference (1022.12 ± 97.90 mm2), and pericardial adipose tissue volume (46.72 ± 36.62 mm3) (p < 0.05). For men, for Group 1 (BMI ≤ 27) each of the measured volumes showed moderate correlation between pericardial adipose tissue and AP chest-diameter (r = 0.429, p < 0.05), whereas in Group 2 (27 < BMI ≤ 31.1), coronary artery volume had a strong association with the AP chest-diameter (r = 0.453, p < 0.05). Conclusion: BMI and thoracic circumference are closely related to variable epi- and pericardial adipose tissue volumes in both males and females during cardiac CT. Implications for practice: Quantification of epi- and pericardial adipose tissue deposits between males and females during cardiac CT may help further categorise coronary artery disease risk when including BMI and thoracic circumference for males and females. © 2021 The College of Radiographer

Community pharmacists' preparedness and responses to COVID-19 pandemic: A multinational study

Background: Community pharmacists play a pivotal role in healthcare worldwide. Their role became more critical during the COVID-19 pandemic. This study aims to investigate the community pharmacists' preparedness and responses to the COVID-19 pandemic and how efficiently they were prepared to contain and prevent the spread of infection. Methods: An online questionnaire was distributed to community pharmacists in Saudi Arabia, Lebanon, and Jordan through social media platforms. A scoring system was developed to measure their level of adherence to the preventive measures of the global infection. Results: The total included responses were 800. Around 44% of the pharmacists reported spending less than 15 min/d reading about COVID-19 updates. Although more than half of them were reviewing official sites, 73% of them were also retrieving information through non-official channels. Additionally, almost 35% of them were directly contacting customers without physical barriers, 81% reported encountering infected customers, and 12% wore the same facial masks for more than a day. Moreover, 58% of the pharmacies reported the absence of door signs requesting infected customers to declare the infection, 43% of the pharmacies were not limiting the number of simultaneous customers, and 70% were not measuring customers' temperatures prior to entry. Collectively, the mean total score of applied protective measures was 10.12 ± 2.77 (out of 17). Conclusion: The level of preparedness of the community pharmacies in these three Middle Eastern countries was not adequate for facing the COVID-19 pandemic. Health authorities in these countries should closely monitor their adherence to the protective guidelines. © 2021 John Wiley & Sons Lt

Poor practice and governance in Lebanese national diagnostic reference levels of adult head and body computed tomography: A nationwide study

Lebanon has one of the highest number of computed tomography (CT) scanners per capita in the world which could likely be one of the causative factors of its high cancer incidence. In this study, we aimed to establish a national diagnostic reference level (NDRL) in adult CT examinations of the head and body in Lebanon. Dose Length Product (DLP) (n = 2730) were recorded in 91 hospitals/centers in Lebanon for head, chest, and abdomen-pelvis CT. Data was obtained from adult patients (≥18 years) with a weight range of 75–80 kg, from January 2018 until December 2019. Then, the median, mean and 75th percentile of the DLP was calculated for each anatomical region. NDRL was reported as the 75th percentile. Then, the established NDRL was benchmarked with international countries as the USA, UK, and Australia. In our study, data were collected from imaging departments (n = 91), with a response rate of 65% of the national total. All CT scanners ranged from 1 to 256 slices. The 75th percentile for the DLP of the head, chest, and abdomen-pelvis CT scan in Lebanon was 1426, 646, and 967 mGy cm respectively. A significant difference in mean DLP of the chest and abdomen-pelvis CT in different governorates was noted with north Lebanon having the highest levels (604 and 882 mGy cm respectively) (p < 0.05). When benchmarked with 18 different countries, Lebanon ranked 2nd, 3rd, and 4th highest in 75th percentile DLP for head, chest, and abdomen-pelvis CT scans respectively. In conclusion, the established Lebanese NDRL for adult routine CT scans of head, chest, and abdomen-pelvis were significantly higher than the reported international radiation dose thresholds. This demonstrates a great scope for radiation dose reduction and the need for urgent intervention of DRL to optimize CT scanning procedures and protocols in Lebanon. © 2021 Elsevier Lt

Spontaneous Pneumomediastinum in Patients Diagnosed with COVID-19: A Case Series with Review of Literature

Background: Spontaneous pneumomediastinum (SPM) is a rare condition defined by the presence of air in the mediastinum in the absence of traumatic or iatrogenic injury. Although the imaging findings and complications of SARS-CoV-2 infection have been reported many times, there are few reports of the prevalence and outcomes of patients with SPM. Purpose: In this paper, we aimed to illustrate the different manifestations, management, and outcome of three cases of SPM in COVID-19 patients and provide an extensive review available literature. Materials and Methods: Detailed report of patients' demographics, clinical presentation, management, and outcome of three cases of COVID-19 induced SPM seen in our institution was provided. Additionally, literature search was employed through March 2021 using Pubmed and Google scholar databases where a total of 22 articles consisting of 35 patients were included. Results: Statistical analysis of the reviewed articles showed that SPM in COVID-19 occurs in patients with a mean age of 55.6 ± 16.7 years. Furthermore, 80% of the 35 patients are males and almost 60% have comorbidities. Intriguingly, SPM in COVID-19 is associated with a 28.5% mortality rate. These findings are consistent with our case series and are different from previous reports of SPM in non-COVID-19 cases where it most commonly occurs in younger individuals and has a self-limiting course with a good outcome. Conclusion: Therefore, SPM in COVID-19 patients occurs in older patients and is potentially associated with a higher mortality rate. Further studies are necessary to assess its role as a prognostic marker of poor outcome. © 2021 The Association of University Radiologist

To repeat or not to repeat: Radiologists demonstrated more decisiveness than their fellow radiographers in reducing the repeat rate during mobile chest radiography

Introduction: Radiologists and radiographers play a complementary role in providing an optimal image quality with decrease radiation dose and proper diagnosis during chest radiographs. We aim Investigate years of experience among radiologists and radiographers on perception of image quality and its impact on repeat rate when evaluating portable pediatric chest radiographs. Methods: IRB approved retrospective study consisted of randomly selected images (n = 131) of pediatric portable chest radiographs. Images were blindly assessed by four radiologists and four radiographers. Readers were asked to assess qualitative and quantitative image quality by rating: image quality, decision to repeat and image technique. All data was compared employing Pearson's Correlation, Visual grading characteristic (VGC) and Cohens' kappa analyses. Results: Image quality: Radiologists (88.4%) rated images as excellent significantly more than radiographers (11.6%), and radiographers (90.1%) as poor significantly more than radiologists (9.9%) (p < 0.05). Repeat: Radiologists (57%) decided not to repeat images significantly more than radiographers (43%) (p < 0.05). Image technique: Radiologists rated images as acceptable (65%) and excellent (97.7%) significantly more than radiographers (35% and 2.3% respectively) (p < 0.05), whereas radiographers (84%) assessed image technique as poor significantly more than radiologists (16%) (p < 0.05). VGC: radiographers had slightly better qualitative evaluation of image quality than radiologists. An association between image quality (p < 0.002) and repeat decision (p < 0.044) with years of experience was established when comparing years of experience with image assessment rubric, while no association was noted with image technique (p < 0.9). Conclusion: Radiologists demonstrated more decisiveness than their fellow radiographers in reducing the repeat rate of portable pediatric chest radiographs. Interestingly, years of experience only seem to affect image technique and image quality assessment among radiologists. Implications for practice: Continuous education of radiographers and close collaboration with radiologists is crucial to achieve optimal image quality and low radiation doses. © 2020 The College of Radiographer

Balancing act between quantitative and qualitative image quality between nonionic iodinated dimer and monomer at various vessel sizes during computed tomography: A phantom study

Purpose: Investigate the impact of nonionic dimer and monomer on iodine quantification in different vessel sizes when employing a vascular specific phantom and varying iodinated contrast media (ICM) concentrations during computed tomography (CT). Materials and Methods: We created a vascular specific phantom (30 cm) to simulate human blood vessel diameters (25 cylinders of different diameters: 10 × 9mm, 10 × 12mm and 5 × 21mm). The phantom was filled with two ICM separately: Group: Iohexol(monomer)350 mg ml-1 and B: Iodixanol(Dimer)320 mg ml-1. Cylinders of same size were filled with increasing ICM concentration(10%-100%) while large cylinders were filled in quartiles(25%-100%). Phantom was scanned with different tube potential (80-140kVp), current (50-400mAs), reconstruction method [filtered back projection (FBP), hybrid-based iterative reconstruction (HBIR) and model-based iterative reconstruction (MBIR)] for each ICM. Chi-square was employed to compare mean opacification, contrast/noise ratio (CNR) and noise. Qualitative analysis was assessed by Visual grading characteristic (VGC) and Cohens-kappa analyses. Results: At 80 and140kVp significant difference in opacification between Group A (2054 ± 1040HU and 1696 ± 1027HU) and B (2169 ± 1105HU and 1568 ± 1034HU) was demonstrated (p 0.05). When comparing image noise, it was higher in Group A compared to B (p < 0.05). CNR was higher in Group B (119.99 ± 126.10HU) than A (107.09 ± 102.56HU) (p < 0.0001). VGC: Group A outperformed B in image opacification in all vessel sizes and ICM concentrations except at medium vessels with concentration group 2(0.4-0.6 mg ml-1). Cohens'-kappa: Agreement in opacification between each ICM group and iodine concentration 1(0-0.3 mg ml-1): κ = 0.253 and 0.014 respectively, concentration 2(0.4-0.6 mg ml-1):κ =-0.017 and-0.005 respectively and concentration 3(0.7-1 mg ml-1):κ = 0.031 and 0.115 respectively. Conclusion: Nonionic dimer (Iodixanol) surpasses monomer (Iohexol) in quantitative image quality assessment by having lower image noise and higher CNR during CT. © 2020 IOP Publishing Ltd