COVID-19 Pandemic Impact on Physicians’ Decision-making: Digoxin Toxicity in View of Combination of Hydroxychloroquine and Azithromycin: A Case Report

BACKGROUND: Since the WHO declaration of COVID-19 being a global pandemic, the population in general and health-care providers, in particular, became under extraordinary pressure that remarkably impacts their decisions at multiple levels as all of us should make decisions quickly while being uncertain in many times. CASE REPORT: We are reporting a 64-year-old lady with a medical history of atrial fibrillation and mitral regurgitation that treated with digoxin and warfarin therapy, she was suspected to be a COVID-19 case and prescribed empirical hydroxychloroquine and azithromycin combination without proper adjustment of her baseline therapy, accordingly she developed adverse effect of this combination in the form of digoxin toxicity and long QT, this case highlights how this unprecedented pandemic affects the decision-making of physicians. CONCLUSION: We should be critical and vigilant in making a decision of prescription or marketing non-evidence-based therapy, and when we are obligated for this decision, we should take all precautions to minimize the adverse effects of these drugs

Adopting a New Training Paradigm to Bridge the Gaps in Cardiology Fellows Training

Specijalizacija u interventnoj kardiologiji ubrzano napreduje, no programi kardiološke specijalizacije ne prate taj napredak u potpunosti. Edukacijsko ozračje koje zdravstvena institucija stvara za osobe koje podučava važna su odrednica za kvalitetu zdravstvenih usluga kojem može ponuditi bolesnicima. Pokušali smo odrediti slabe točke u tradicionalnom programu specijalizacije iz kardiologije kroz učestalo skupljanje povratnih informacija od specijalizanata koji su ga pohađali. Nakon toga pokušali smo premostiti jaz u znanju i praksi uspostavljanjem nove edukacijske paradigme koja se sastojala u uvođenju pet dodatnih tečaja u edukaciji specijalizanata na zadnjoj godini specijalizacije, koji su uključivali trening implantacije i programiranja kardioloških uređaja, osnove primjene holter sustava, osnove elektrofiziologije, pristup i zbrinjavanje prirođenih srčanih bolesti u odraslih te sudjelovanje u radu odjela za patološka kardiološka stanja u trudnoći. Nakon što su svi specijalizanti dovršili novi program treninga, ispunili su anketu kojom smo dobili povratnu informaciju o njihovoj razini zadovoljstva svakim tečajem, prednostima i nedostatcima u svakom tečaju te njihovim prijedlozima glede budućih edukacijskih programa za poboljšanje kompetencije idućih generacija specijalizanata. Anketa je pokazala da je razina zadovoljstva bila najveća za tečajeve u odjelima za elektrofiziologiju i patološka kardiološka stanja u trudnoći, a najniža razina zadovoljstva bila je vezana za tečaj implantacije kardioloških uređaja, prije svega zbog ograničena praktičnog treninga. Ovaj je program nudio jednake mogućnosti i prilike svim kandidatima u poboljšanju znanja i povećanju sposobnosti kako bi poboljšali kompetencije, što će posljedično poboljšati i kardiovaskularnu njegu.Interventional cardiology specialty is progressing at a rapid pace, but the progress in cardiology fellowship programs does not parallel it fully. The educational and training environment provided by a healthcare facility to its trainees is a major determinant of the healthcare services it can provide to patients. Keeping that in mind, we tried to determine the fragile points in the traditional cardiology fellowship program by continuous precise feedback from fellows in training. We then tried to bridge the practice and teaching gaps by establishing a new training paradigm that implemented five courses in training of the final-year fellows, including training on device implantation, device programming and Holter basics, electrophysiology study basics, approaching and managing adult congenital heart disease, and cardio-maternal unit attendance. Once all fellows in training completed their new training program, they were surveyed for feedback regarding their satisfaction level with each course, privileges and educational pitfalls of each course, as well as their suggestions for future training programs for the next fellows to further improve competency. The survey found that the level of satisfaction was highest with electrophysiology and cardio maternal unit training, while the lowest satisfaction level was reported for the device implantation course, mainly due to limited hands-on training. This program provides equal opportunities to all candidates in order to improve knowledge and upgrade skills to improve the competencies of this workforce nucleus which will subsequently impact cardiovascular care

Clinical Evaluation of Pit and Fissure Sealants Placed by Undergraduate Dental Students in 5-15 Years-old Children in Iraq

Objective: To clinically evaluate the retention and marginal discoloration of pit and fissure sealants applied to primary and permanent teeth. Material and Methods: The study population encompassed of 5-15 years- old children. After consenting, a light-curing sealant was applied to etched pits and fissures of occlusal surfaces of selected sound teeth. The retention rate and marginal discoloration were assessed, 3 months after application of the sealants based on the criteria proposed by Simonsen’s criteria (total retention: score 0, partial loss: score 1, and total loss: score 2). Each tooth was considered as an independent sample during analysis. Results: The achieved sample size was 43 children aged 5-15 years (mean age=10.0 years). Therefore, data of 100 teeth from 43 children were used for the final analysis. The percentage of completely retained sealants (59%) was higher than the percentage of partially retained sealants (23%) and completely missing sealants (18%) after 3 months follow up. Out of 100 sealed teeth, 60% were either had marginal discoloration or completely missing. Using the Mann-Whitney test, there was a statistically significant difference (p<0.05) between primary and permanent teeth in terms of retention. However, there was no statistical difference (p>0.05) between upper and lower teeth in terms of retention. Conclusion: The success rate of fissure sealants after 3 months follow-up was satisfactory

Lidar Point Cloud compression, processing and learning for Autonomous Driving

As technology advances, cities are getting smarter. Smart mobility is the key element in smart cities and Autonomous Driving (AV) are an essential part of smart mobility. However, the vulnerability of unmanned vehicles can also affect the value of life and human safety. In this paper, we provide a comprehensive analysis of 3D Point-Cloud (3DPC) processing and learning in terms of development, advancement, and performance for the AV system. 3DPC has recently attracted growing interest due to its extensive applications, such as autonomous driving, computer vision, and robotics. Light Detection and Ranging Sensors (LiDAR) is one of the most significant sensors in AV, which collects 3DPC that can accurately capture the outer surfaces of scenes and objects. Learning and processing tools in the 3DPC are essential for creating maps, perceptions, and localization devices in AV. The intention behind 3DPC learning and practical processing tools is to be considered the most essential modules to create, locate, and perceive maps in an AV system. The goal of the study is to know ``what has been tested in AV system so far and what is necessary to make it safer and more practical in AV system.'' We also provide insights into the necessary open problems that are required to be resolved in the future

The burden of ischemic heart disease and the epidemiologic transition in the Eastern Mediterranean Region: 1990-2019

It has been estimated that in the next decade, IHD prevalence, DALYs and deaths will increase more significantly in EMR than in any other region of the world. This study aims to provide a comprehensive description of the trends in the burden of ischemic heart disease (IHD) across the countries of the Eastern Mediterranean Region (EMR) from 1990 to 2019. Data on IHD prevalence, disability-adjusted life years (DALYs), mortality, DALYs attributable to risk factors, healthcare access and quality index (HAQ), and universal health coverage (UHC) were extracted from the Global Burden of Disease (GBD) database for EMR countries. The data were stratified based on the social demographic index (SDI). Information on cardiac rehabilitation was obtained from publications by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR), and additional country-specific data were obtained through advanced search methods. Age standardization was performed using the direct method, applying the estimated age structure of the global population from 2019. Uncertainty intervals were calculated through 1000 iterations, and the 2.5th and 97.5th percentiles were derived from these calculations. The age-standardized prevalence of IHD in the EMR increased from 5.0% to 5.5% between 1990 and 2019, while it decreased at the global level. In the EMR, the age-standardized rates of IHD mortality and DALYs decreased by 11.4% and 15.4%, respectively, during the study period, although both rates remained higher than the global rates. The burden of IHD was found to be higher in males compared to females. Bahrain exhibited the highest decrease in age-standardized prevalence (-3.7%), mortality (-65.0%), and DALYs (-69.1%) rates among the EMR countries. Conversely, Oman experienced the highest increase in prevalence (14.5%), while Pakistan had the greatest increase in mortality (30.0%) and DALYs (32.0%) rates. The top three risk factors contributing to IHD DALYs in the EMR in 2019 were high systolic blood pressure, high low-density lipoprotein cholesterol, and particulate matter pollution. The trend analysis over the 29-year period (1990-2019) revealed that high fasting plasma glucose (64.0%) and high body mass index (23.4%) exhibited increasing trends as attributed risk factors for IHD DALYs in the EMR. Our findings indicate an increasing trend in the prevalence of IHD and a decrease in mortality and DALYs in the EMR. These results emphasize the need for well-planned prevention and treatment strategies to address the risk factors associated with IHD. It is crucial for the countries in this region to prioritize the development and implementation of programs focused on health promotion, education, prevention, and medical care.We thank the Institute of Health Metrics and Evaluation for providing all data analyzed in this study. This study is funded by Bill & Melinda Gates Foundation [grant number OPP1152504]. Also we would like to extend our thanks to the GBD team for allowing us to access their free, comprehensive data base.Scopu

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

World Heart Federation Roadmap on Atrial Fibrillation – A 2020 Update

The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world’s population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them.Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow.This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

BHPR research: qualitative1. Complex reasoning determines patients' perception of outcome following foot surgery in rheumatoid arhtritis

Background: Foot surgery is common in patients with RA but research into surgical outcomes is limited and conceptually flawed as current outcome measures lack face validity: to date no one has asked patients what is important to them. This study aimed to determine which factors are important to patients when evaluating the success of foot surgery in RA Methods: Semi structured interviews of RA patients who had undergone foot surgery were conducted and transcribed verbatim. Thematic analysis of interviews was conducted to explore issues that were important to patients. Results: 11 RA patients (9 ♂, mean age 59, dis dur = 22yrs, mean of 3 yrs post op) with mixed experiences of foot surgery were interviewed. Patients interpreted outcome in respect to a multitude of factors, frequently positive change in one aspect contrasted with negative opinions about another. Overall, four major themes emerged. Function: Functional ability & participation in valued activities were very important to patients. Walking ability was a key concern but patients interpreted levels of activity in light of other aspects of their disease, reflecting on change in functional ability more than overall level. Positive feelings of improved mobility were often moderated by negative self perception ("I mean, I still walk like a waddling duck”). Appearance: Appearance was important to almost all patients but perhaps the most complex theme of all. Physical appearance, foot shape, and footwear were closely interlinked, yet patients saw these as distinct separate concepts. Patients need to legitimize these feelings was clear and they frequently entered into a defensive repertoire ("it's not cosmetic surgery; it's something that's more important than that, you know?”). Clinician opinion: Surgeons' post operative evaluation of the procedure was very influential. The impact of this appraisal continued to affect patients' lasting impression irrespective of how the outcome compared to their initial goals ("when he'd done it ... he said that hasn't worked as good as he'd wanted to ... but the pain has gone”). Pain: Whilst pain was important to almost all patients, it appeared to be less important than the other themes. Pain was predominately raised when it influenced other themes, such as function; many still felt the need to legitimize their foot pain in order for health professionals to take it seriously ("in the end I went to my GP because it had happened a few times and I went to an orthopaedic surgeon who was quite dismissive of it, it was like what are you complaining about”). Conclusions: Patients interpret the outcome of foot surgery using a multitude of interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than other factors in the overall outcome of the surgery. Future research into foot surgery should incorporate the complexity of how patients determine their outcome Disclosure statement: All authors have declared no conflicts of interes