International Guideline on Dose Prioritization and Acceptance Criteria in Radiation Therapy Planning for Nasopharyngeal Carcinoma

Purpose: The treatment of nasopharyngeal carcinoma requires high radiation doses. The balance of the risks of local recurrence owing to inadequate tumor coverage versus the potential damage to the adjacent organs at risk (OARs) is of critical importance. With advancements in technology, high target conformality is possible. Nonetheless, to achieve the best possible dose distribution, optimal setting of dose targets and dose prioritization for tumor volumes and various OARs is fundamental. Radiation doses should always be guided by the As Low As Reasonably Practicable principle. There are marked variations in practice. This study aimed to develop a guideline to serve as a global practical reference. Methods and Materials: A literature search on dose tolerances and normal-tissue complications after treatment for nasopharyngeal carcinoma was conducted. In addition, published guidelines and protocols on dose prioritization and constraints were reviewed. A text document and preliminary set of variants was circulated to a panel of international experts with publications or extensive experience in the field. An anonymized voting process was conducted to rank the proposed variants. A summary of the initial voting and different opinions expressed by members were then recirculated to the whole panel for review and reconsideration. Based on the comments of the panel, a refined second proposal was recirculated to the same panel. The current guideline was based on majority voting after repeated iteration for final agreement. Results: Variation in opinion among international experts was repeatedly iterated to develop a guideline describing appropriate dose prioritization and constraints. The percentage of final agreement on the recommended parameters and alternative views is shown. The rationale for the recommendations and the limitations of current evidence are discussed. Conclusions: Through this comprehensive review of available evidence and interactive exchange of vast experience by international experts, a guideline was developed to provide a practical reference for setting dose prioritization and acceptance criteria for tumor volumes and OARs. The final decision on the treatment prescription should be based on the individual clinical situation and the patient's acceptance of optimal balance of risk. (C) 2019 Elsevier Inc. All rights reserved

International Recommendations on Reirradiation by Intensity Modulated Radiation Therapy for Locally Recurrent Nasopharyngeal Carcinoma

Purpose: Reirradiation for locally recurrent nasopharyngeal carcinoma (NPC) is challenging because prior radiation dose delivered in the first course is often close to the tolerance limit of surrounding normal structures. A delicate balance between achieving local salvage and minimizing treatment toxicities is needed. However, high-level evidence is lacking because available reports are mostly retrospective studies on small series of patients. Pragmatic consensus guidelines, based on an extensive literature search and the pooling of opinions by leading specialists, will provide a useful reference to assist decision-making for these difficult decisions. Methods and Materials: A thorough review of available literature on recurrent NPC was conducted. A set of questions and preliminary draft guideline was circulated to a panel of international specialists with extensive experience in this field for voting on controversial areas and comments. A refined second proposal, based on a summary of the initial voting and different opinions expressed, was recirculated to the whole panel for review and reconsideration. The current guideline was based on majority voting after repeated iteration for final agreement. Results: The initial round of questions showed variations in clinical practice even among the specialists, reflecting the lack of high-quality supporting data and the difficulties in formulating clinical decisions. Through exchange of comments and iterative revisions, recommendations with high-to-moderate agreement were formulated on general treatment strategies and details of reirradiation (including patient selection, targets contouring, dose prescription, and constraints). Conclusion: This paper provides useful reference on radical salvage treatment strategies for recurrent NPC and optimization of reirradiation through review of published evidence and consensus building. However, the final decision by the attending clinician must include full consideration of an individual patient's condition, understanding of the delicate balance between risk and benefits, and acceptance of risk of complications. (C) 2021 Elsevier Inc. All rights reserved

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine

[This corrects the article DOI: 10.1186/s13054-016-1208-6.]

Ahsa region study in their internal situation in 1871 1913 إقليم الإحساء دراسة في أوضاعه الداخلية1871 ـ 1913م

Ahsa is the eastern region of Saudi Arabia, a collection of sensory an earth-coated sand store rainwater so that it can be obtained pure fresh and frequent Alahsah this site known region Ahsa, extending back to the times of some degree foot to form an important part of the land of the Arabian Peninsula and commercial center and market active trading caravans from Syria, Hijaz, Iraq and India to, successive this region since ancient states and folks various as the form of the Phoenicians first installments of these migrations was followed Jerhaúaon (a branch of the Chaldeans) and has since joined the Arab Islamic state after Islamic conquest and then relay the verdict Alaaonion and the franchiser and subsequently underwent the region of the occupation of the Portuguese, who was expelled by the Ottomans Year 1551. The choice for this study of Ahsa based on the importance of geographical, historical and internal conflicts dropped بضلالها on the overall situation in the region, which has assumed the important position after that it became a base for launching towards areas Arabian Gulf Coast and had been fighting between the brothers Abdullah and Saud sons Faisal bin Turki Al Saud leadership and influence a significant impact in the loss of Ahsa a certain length of time, however, the Ottomans, who continued their occupation until 1913, a year in which enables Abdul Aziz Al Saud of ending the Ottoman presence to become the ruler of Najd and Ahsa 1914

Potential Metabolite Nymphayol Isolated from Water Lily (Nymphaea stellata) Flower Inhibits MCF-7 Human Breast Cancer Cell Growth via Upregulation of Cdkn2a, pRb2, p53 and Downregulation of PCNA mRNA Expressions

Controlled production of cyclin dependent kinases (CDK) and stabilization of tumor suppressor genes are the most important factors involved in preventing carcinogenesis. The present study aimed to explore the cyclin dependent apoptotic effect of nymphayol on breast cancer MCF-7 cells. In our previous study, we isolated the crystal from a chloroform extract of Nymphaea stellata flower petals and it was confirmed as nymphayol (17-(hexan-2-yl)-10,13-dimethylhexadecahydro-1H-cyclopenta[a]phenanthren-3-ol) using x-ray diffraction (XRD), Fourier transform infrared (FTIR), and mass spectroscopy (MS) methods. The cytotoxic effect of nymphayol on MCF-7 cells were analyzed using the 3-(4,5-dimethylthiazol-2yl)-2,5-diphenyl tetrazolium bromide (MTT) assay. The cellular and nuclear damage was determined using propidium iodide (PI) and acridine orange/ethidium bromide (AO/ErBr) staining. Tumor suppressor and apoptosis related mRNA transcript levels were determined using real-time polymerase chain reaction (RT-PCR). Nymphayol potentially inhibits MCF-7 cell viability up to 78%, and the IC50 value was observed as 2.8 µM in 24 h and 1.4 µM in 48 h. Treatment with nymphayol significantly increased reactive oxygen species (ROS) level and the tunnel assay confirmed DNA damage. We found characteristically 76% apoptotic cells and 9% necrotic cells in PI and AO/ErBr staining after 48 h treatment with 2.8 µM of nymphayol. Gene expression analysis confirmed significantly (p ≤ 0.001) increased mRNA levels of cyclin dependent kinase inhibitor 2A (Cdkn2a), retinoblastoma protein 2 (pRb2), p53, nuclear factor erythroid 2-factor 2 (Nrf2), caspase-3, and decreased B-cell lymphoma 2 (Bcl-2), murine double minute 2 (mdm2), and proliferating cell nuclear antigen (PCNA) expression after 48 h. Nymphayol effectively inhibited breast cancer cell viability, and is associated with early expression of Cdkn2a, pRb2, and activation of p53 and caspases

Development of type 2 diabetes mellitus after gestational diabetes in a cohort in KSA: Prevalence and risk factors

Objectives: KSA has the highest prevalence of diabetes mellitus among Middle Eastern countries with a prevalence range of 21%–24%. Gestational diabetes (GDM) is a well-known risk factor for type 2 diabetes mellitus (T2DM). GDM is associated with a 7-fold increased risk of T2DM. Thus, this research assessed the prevalence and risk factors associated with the development T2DM in a cohort of patients with GDM in KSA. Methods: The medical records of patients with GDM who visited the outpatient clinics of a tertiary care hospital from 2011 to 2014 were included in this study. Patients with a prior diagnosis of diabetes mellitus before pregnancy and those with GDM who did not have postpartum diabetes screening were excluded. Results: A total of 123 women with GDM and underwent postpartum diabetes screening, 82 (67%) developed T2DM based on follow-up records. Approximately 45% (37/82) of patients who developed T2DM were screened ≤6 months after delivery, whereas 55%(45/82) were screened >6 months after delivery. Older patients, patients who had a higher number of pregnancies (gravidity and parity), and patients with previous GDM were more likely to develop T2DM. Conclusion: In KSA, women who developed GDM, particularly those who are older, multigravid, and multiparous and who have a prior history of GDM, are at an increased risk of developing T2DM. Postpartum diabetes screening of patients with GDM within the recommended period need to be improved. Keywords: Gestational diabetes, Postpartum, Risk factors, Screening, Type 2 diabete

Assessment of knowledge, attitude, and practices of acute kidney injury incidence with co-administration of piperacillin/tazobactam and vancomycin among healthcare workers: A cross-sectional study

Background: No studies have identified a link between acute kidney injury (AKI) incidence due to the co-administration of vancomycin and piperacillin/tazobactam (VPT) and healthcare providers’ knowledge, attitudes, and practices. We aimed to (1) assess the knowledge, attitudes, and practices towards AKI due to VPT co-administration among healthcare providers in Saudi Arabia, and (2) examine the relationship between healthcare providers’ knowledge and attitudes about AKI due to VPT co-administration and their practices. Methods: This cross-sectional study was conducted between February 2022 and April 2022. Healthcare providers, including physicians, pharmacists, and nurses, were included in the study population. The correlation coefficient assessed the relationship between knowledge, attitude, and practice. Spearman’s rho was used as a test statistic. Results: Of the invited healthcare providers, 192 responded to the survey. A significant difference in knowledge was found among healthcare providers for two variables: the definition of AKI (p < 0.001) and appropriate management of AKI due to VPT (p = 0.002). Physicians were found to rely less on the most common causative organisms of infection to guide empirical antibiotic therapy (p < 0.001). In addition, physicians were less likely to switch piperacillin/tazobactam to cefepime or meropenem in combination with vancomycin with AKI incidence (p = 0.001). A positive attitude towards the perceived AKI risk with VPT was positively correlated with avoiding using VPT unless no alternatives were available (Rho = 0.336) and taking protective measures when using VPT (Rho = 0.461). Conclusion: Deviation has been observed in the knowledge, attitudes, and practices of AKI incidence with the co-administration of piperacillin/tazobactam and vancomycin among healthcare workers. Interventions at the organizational level are recommended to guide best practices

Highlights on the Management of Oligometastatic Disease

Purpose: The understanding of oligometastatic disease (OMD) is rapidly evolving and with this comes the ability to utilize a number of modalities that excel in the localized control of disease. It has been identified that there are no clear guidelines based on high-level evidence to standardized approaches toward the management of OMD. These highlights have been developed to provide a road map for all health-care professionals who are involved in the management of OMD to support standardized patient care. Methods: The Saudi Lung Cancer Guidelines Committee is a part of the Saudi Lung Cancer Association which, in turn, is part of the Saudi Thoracic Society. Considering that lung cancer constitutes a major proportion of OMD prevalence, the committee took the initiative to develop national highlights to support the management of OMD within Saudi Arabia. The committee members are national clinical leaders who collaborated with international expertise to establish these highlights to serve as a general clinical pathway in the management of OMD. Results: Standardization of the indications to diagnose oligometastases and patient selection criteria including ineligibility criteria for treatment are the basis of the highlights. Treatment approaches including surgical and the variety of radiotherapeutical options are discussed in relation to specific oligometastatic sites. Acceptable measurements for response to treatment and the future for the treatment of OMD conclude the development of the highlights. Conclusion: These are the first national highlights addressing this important disease in oncology. The implementation of these highlights as guidelines requires a robust multidisciplinary team and access to specific technology and expertise. These highlights are based on the most recent findings within the literature but will require repeated review and updating due to this rapidly evolving field in disease management