Appropriateness of Emergency Referrals Made by Primary Care Clinicians: A cross-sectional review of referral notes

Objectives: To evaluate the appropriateness of emergency referrals made by primary care clinicians and determine factors contributing to inappropriate referrals. Methods: A cross sectional study, based on referral notes review. Patients referred to Khawla Hospital emergency department by a primary care clinician in Muscat governorate were randomly selected. Referral notes were reviewed by five family physicians. Appropriateness of referrals were evaluated according to primary care referral protocol. Any referral document that deviated from the protocol was classified as inappropriate. The prevalence and characteristics of inappropriate referrals were identified. Factors contributing to inappropriate referral were determined using multivariable logistic regression. Results: A total of 591 referrals were reviewed. 354 (59.9%) were classified as inappropriate. The reason for inappropriate classification was due to inadequate medical notes 291 (82.2%), lack of provisional diagnosis 176 (49.7%), misdirected to a non-concerned emergency 30 (8.4%), misclassification of urgency in which 107 (30.2%) were urgent and 45 (12.7%) were routine. After adjusting for multiple variables, insufficient clinical notes, unavailability of referral guidelines, and lack of expertise were strong determinants of inappropriate referral with odds ratio 62.52 (95% CI: 32.04 - 121.96), 2.88 (95% CI: 1.40 – 5.92), and 9.37 (95% CI: 4.09 – 21.43), respectively. Conclusion: While most referrals made by primary care clinicians required emergency management, the majority were identified as inappropriate and that was mainly due to insufficient clinical documentation. Inadequate clinical notes, lack of national guidelines and expertise were found to be strong predictors for inappropriate emergency referrals. Keywords: Referral and consultation, hospital referral; emergency; primary care; physicians; documentation; records; guidelines

Chemosensetizing and cardioprotective effects of resveratrol in doxorubicin- treated animals

BACKGROUND: Doxorubicin (DOX), an anthracycline antibiotic is one of the most effective anticancer drug used in the treatment of variety of cancers .Its use is limited by its cardiotoxicity. The present study was designed to assess the role of a natural product resveratrol (RSVL) on sensitization of mammary carcinoma (Ehrlich ascites carcinoma) to the action of DOX and at the same time its protective effect against DOX-induced cardiotoxicity in rats. METHODS: Ehrlich ascites carcinoma bearing mice were used in this study. Percent survival of tumor bearing mice was used for determination of the Cytotoxic activity of DOX in presence and absence of RSVL. Uptake and cell cycle effect of DOX in tumor cells in the presence of RSVL was also determined. Histopatholgical examination of heart tissues after DOX and/or RSVL therapy was also investigated. RESULTS: DOX at a dose level of 15 mg/kg increased the mean survival time of tumor bearing mice to 21 days compared with 15 days for non tumor-bearing control mice. Administration of RSVL at a dose level of 10 mg/kg simultaneously with DOX increased the mean survival time to 30 days with 70% survival of the tumor-bearing animals. RSVL increased the intracellular level of DOX and there was a strong correlation between the high cellular level of DOX and its cytotoxic activity. Moreover, RSVL treatment showed 4.8 fold inhibition in proliferation index of cells treated with DOX. Histopathological analysis of rat heart tissue after a single dose of DOX (20 mg/kg) showed myocytolysis with congestion of blood vessels, cytoplasmic vacuolization and fragmentation. Concomitant treatment with RSVL, fragmentation of the muscle fiber revealed normal muscle fiber. CONCLUSION: This study suggests that RSVL could increase the cytotoxic activity of DOX and at the same time protect against its cardiotoxicity

The attitudes of dental interns to the use of the rubber dam at Riyadh dental colleges

Background : The rubber dam is one of the best tools for tooth isolation and infection control in the dental field. Our aim is to evaluate the attitudes toward the use of rubber dams by dental interns in Riyadh Dental Colleges (RCsDP) and determine the barriers to their use. Materials and Methods: A self-administered questionnaire was designed and used for data collection. 150 questionnaires were distributed by hand to the dental interns of RCsDP over a period of two weeks. Information sought included the attitudes toward and difficulties for the use of the rubber dam, the time needed to apply the rubber dam, and the patients′ allergic history of the rubber dam. Respondents were asked to state their preference on a five point Likert type scale ranging from "strongly dislike" to "strongly like". The information and data of the completed questionnaires were statistically analyzed using Mann-Whitney U test and Friedman test. Results: Of 150 questionnaires distributed, 150 were completed and returned (response rate = 100%). Of those, 46.7% were males and 53.3% were females. In general; (43.3%), interns strongly liked the use of the rubber dam and the rest (46.7%) liked the use of the rubber dam. The majority of respondents liked to use rubber dam in direct restorations more than in indirect restorations and 46.7% strongly liked to use it in posterior teeth for composite restoration. Most dental interns felt that they would strongly like to use a rubber dam for endodontic treatment whether in posterior teeth (73.3%) or anterior teeth (68.7%). 66.7% of interns asked their patients if they had an allergy to latex prior to the use of the rubber dam. Child behavior (mean rank about seven) is the most important reason for not using rubber dam. The time is taken to apply the rubber dam was less than five minutes in most cases. Conclusion: Most dental interns prefer to use rubber dams in the general dental field and are enthusiastic to use it in future

Chemosensetizing and cardioprotective effects of resveratrol in doxorubicin- treated animals

Doxorubicin (DOX), an anthracycline antibiotic is one of the most effective anticancer drug used in the treatment of variety of cancers .Its use is limited by its cardiotoxicity. The present study was designed to assess the role of a natural product resveratrol (RSVL) on sensitization of mammary carcinoma (Ehrlich ascites carcinoma) to the action of DOX and at the same time its protective effect against DOX-induced cardiotoxicity in rats.Ehrlich ascites carcinoma bearing mice were used in this study. Percent survival of tumor bearing mice was used for determination of the Cytotoxic activity of DOX in presence and absence of RSVL. Uptake and cell cycle effect of DOX in tumor cells in the presence of RSVL was also determined. Histopatholgical examination of heart tissues after DOX and/or RSVL therapy was also investigated.DOX at a dose level of 15?mg/kg increased the mean survival time of tumor bearing mice to 21?days compared with 15?days for non tumor-bearing control mice. Administration of RSVL at a dose level of 10?mg/kg simultaneously with DOX increased the mean survival time to 30?days with 70% survival of the tumor-bearing animals. RSVL increased the intracellular level of DOX and there was a strong correlation between the high cellular level of DOX and its cytotoxic activity. Moreover, RSVL treatment showed 4.8 fold inhibition in proliferation index of cells treated with DOX. Histopathological analysis of rat heart tissue after a single dose of DOX (20?mg/kg) showed myocytolysis with congestion of blood vessels, cytoplasmic vacuolization and fragmentation. Concomitant treatment with RSVL, fragmentation of the muscle fiber revealed normal muscle fiber.This study suggests that RSVL could increase the cytotoxic activity of DOX and at the same time protect against its cardiotoxicity

The strategic plan for combating antimicrobial resistance in Gulf Cooperation Council States

Summary: The Gulf Cooperation Council Center for Infection Control (GCC-IC) has placed the emergence of antimicrobial resistance (AMR) on the top of its agenda for the past four years. The board members have developed the initial draft for the GCC strategic plan for combating AMR in 2014. The strategic plan stems from the WHO mandate to combat AMR at all levels. The need for engaging a large number of stakeholders has prompted the GCC-IC to engage a wider core of professionals in finalizing the plan. A multi-disciplinary group of more than 40 experts were then identified. And a workshop was conducted in Riyadh January 2015 and included, for the first time, representation of relevant ministries and agencies as well as international experts in the field. Participants worked over a period of two and a half days in different groups. International experts shared the global experiences and challenges in addressing human, food, animal, and environmental aspects of controlling AMR. Participants were then divided into 4 groups each to address the human, animal, microbiological and diagnostic, or the environmental aspect of AMR. At the end of the workshop, the strategic plan was revised and endorsed by all participants. The GCC-IC board members then approved it as the strategic plan for AMR. The document produced here is the first GCC strategic plan addressing AMR, which shall be adopted by GCC countries to develop country-based plans and related key performance indicators (KPIs). It is now the role of each country to identify the body that will be accountable for implementing the plan at the country level. Keywords: Strategic plan, Antimicrobial resistance, AMR, GCC, Saudi Arabia, United Arab Emirates, Qatar, Bahrain, Oman, Kuwai

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population