The world is waiting, use sequential analysis and get us the evidence-based treatment we need for COVID-19

In spite of the relatively high morbidity and mortality, there is no approved medication yet for COVID-19. There are more than 200 ongoing trials on different drugs or vaccines, but new medications may take until 2021 to develop. Defining the optimal number of patients to be included in a study is a considerable challenge in these interventional researches. Ethical considerations prompt researchers to minimize the number of patients included in a trial. This gains particular importance when the disease is rare or lethal which is particularly so in the case of COVID-19. It is of paramount importance to explore some of the available tools that could help accelerate the adoption of any or some of the many proposed modalities for the treatment of diseases. These tools should be effective, yet efficient, for rapid testing of such treatments. Sequential analysis has not been frequently used in many clinical trials where it should have been used. None of the authors in published literature, as far as we know, used sequential analysis techniques to test potential drugs for COVID-19. In addition to its usefulness when the results of new forms of treatment are quickly needed, other important benefit of sequential analysis includes the ability to reach a similar conclusion about the utility of a new drug without unduly exposing more patients to the side effect of the old drug, in particularly, for the treatment of a rare disease

Bacteriology of lacrimal drainage system following obstruction of the nasolacrimal duct in a reference Population

Context:Lacrimal drainage system obstruction gives discomfort to patients and threatens intraocular surgeries by infection, thus, knowledge of its bacteriology leads to the choice of effective therapy.Aim:To determine the bacteriology of nasolacrimal duct obstruction in an adult Libyan patient population and to analyze the appropriate antimicrobial therapy based on susceptibility testing.Settings and Design:A prospective study was conducted at the Great River Eye hospital, Benghazi/Libya in the period between September 2005 and February 2007.Methods:Lacrimal swab materials collected from patients aged 1862 years who were diagnosed as having lacrimal passage obstruction and referred for lacrimal drainage surgery. The specimens were cultured and results analyzed.Results:Of 86 cases, 87.2% yielded a positive culture result. The majority of microorganisms were gram positive bacteria (73.3%) with Staphylococcus Aureus being the most frequently cultured species (36%) of the sample. Gram negative bacteria represented 26.7% of the isolates. The most common gram negative bacteria were Pseudomonas, Klebsiella, and E. coli which were isolated in 8% of the cases each. Staphylococcus aureus was isolated from 28.6% of cases having epiphora with no clinical signs of lacrimal drainage system infection. Ciprofloxacin (96%) and Gentamycin (94.7%) were found to be the most sensitive antibiotics against isolated organisms.Conclusions:Adult patients with lacrimal drainage system obstruction harbor microorganisms in their lacrimal sacs indicating the importance of investigating patients before planning for intraocular surgeries and considering prophylactic use of antibiotics before lacrimal drainage procedures

Tooth size discrepancy in different malocclusion groups in Libya: a pilot study

Background: Orthodontists need to evaluate intermaxillary tooth size discrepancy (TSD) prior to initiating treatment in order to achieve a stable treatment. Thus, the aim of the present study was to determine the prevalence of TSD in Libyan subjects among different malocclusion groups. Methods: A sample of 60 dental casts of Libyan subjects with different types of malocclusions (Class I, Class II div 1 and Class III) were included in the study. Each malocclusion group (20 dental casts) included equal numbers of males and females, 12-17 years of age. Mesio-Distal tooth measurements were extracted to compute the anterior and overall TSD ratios. Paired Student t-test was used to detect significant discrepancies between the paired teeth measurements. Analysis of Variance (ANOVA) and Tukey Honestly tests were undertaken to detect significant discrepancies among the malocclusion groups. Results: Paired t-test revealed that there were no significant discrepancies between the paired tooth widths except for the upper first molars, upper first premolars, lower lateral incisors and lower canines (P<0.010). ANOVA found no significant differences in the mean anterior TSD ratio in regard to malocclusion groups. However, a significant disparity was noticed in the mean overall TSD ratio among the different malocclusion categories (P<0.04). Conclusion: Statistically significant TSD between the examined malocclusion groups were observed only in the mean overall TSD ratio

Review article: risk factors for non-communicable diseases in Libya

This review article highlights the current situation of some non-communicable diseases in Libya and factors contributing to its prevalence such as obesity, diabetes, cardiovascular diseases (CVD), high blood pressure and cancer. Obesity is a global epidemic resulting in major morbidity and premature death. Between 26-41% among adult Libyan women and 11¬21 % among adult Libyan men (about 64% of Libyan adults are either overweight or obese), obesity progressively increasing with age, and two times more common among Libyan women than men. Hypertension is a common co-morbidity of diabetes, affecting 20-60% of people with diabetes. Hypertension is also a major risk factor for CVD as well as microvascular complications such as retinopathy and nephropathy. About 68.4% of Libyan males and 48.4 % of Libyan females who suffer from high blood pressure are under treatment. The average rate of those who suffer from diabetes mellitus among Libyans reached between 11 ¬ 23.3 % for both sexes. The main causes of death are cardiovascular diseases (43%), cancer (14%), chronic respiratory diseases (4%), diabetes (5%), other Non-communicable diseases (NCDs) (12%), communicable maternal perinatal and nutritional conditions (10%), and road traffic injuries (12%). The prevalence of risk factors for non-communicable diseases has risen as a result of changing lifestyles. More than 30% of the adult male population smokes regularly. Approximately, 1.2 percent of the population is blind, mainly due to cataract. Trachoma remains endemic in some pockets in the country. Road traffic crashes, which result in 6 deaths per day and even higher figures for disability, account for a significant burden of disease

Vesicovaginal fistula diagnosis and repair, Benghazi, Libya (nine years of of experience)

Introduction: Although most of vesicovaginal fistulas (VVF) are iatrogenic, they can also occur as a result of congenital anomalies, neoplastic changes, and complications of radiotherapy. In rural areas, the obstructed labor may lead to the development of VVF. However, the most common cause of VVF in developed areas is iatrogenic damage of the bladder tissue.Aim: To confirm that the immediate repair of iatrogenic urinary bladder injures during obstetric or gynecological surgeries prevents VVF formation, and to identify optimal time and outcome of surgical techniques of VVF repair.Patients & Methods: Prospective study was carried over 9 years and included 95 patients. These patients were divided into two groups; one group underwent immediate intra-operative repair of urinary bladder injuries (n=76), while other group presented with VVF and underwent either reconstructive or urinary diversion surgeries on elective bases (n=19).Results: The mean age of 19 cases having VVF was 29.4 ± 8.4 years. One case was missed and other 18 cases underwent abdominal repair (n=8), vaginal repair (n=5) and permanent urinary diversion (n=5). The time of repair ranged from 2 day to 7 months after detection of VVF. The success rate of post-surgical VVF repair was 92.3%.Conclusion: Immediate repair of urinary bladder injuries during obstetric or gynecological surgeries prevents development of VVF. Post-surgical VVF repair can be done in first post-operative days before inflammatory changes takes place. The result of VVF repair depends on the experience of the surgeon rather than the used surgical techniques

"Gunshot injury to the pelvis".The bullet voided through the urethra

Gunshot injuries (GSIs) are considered as an emergency and life threatening. The gunshots injuries to the urinary tract are uncommon. The high-velocity of bullet can cause both a penetrating injury to the target organs as well as blast injury to nearby structures, in addition to thermal injuries. In most of the cases, laparotomy is required to remove the bullet and to repair the injuries. The phenomenon of spontaneous migration of retained bullet to different parts of body has been described in the medical literature. Here, we present a patient who sustained penetrating GSI to the pelvis, without organ injuries, including the bladder. The bullet initially was retained within peri-vesical fat and the bladder wall while the mucosa remained intact, then it migrated into the bladder and came out through the urethra during voiding on the sixth day after injury

Reduction of Cholesterol and Fasting Blood Sugar Levels by One Month Supplementation of Fresh Garlic in Diabetic Libyan Patients: A Double Blind, Baseline Controlled Study

Background: The therapeutic effects of fresh garlic remain controversial. The aim of this study is to investigate whether supplementation of fresh garlic could improve blood glucose and cholesterol profile in Libyan diabetic patients with moderate blood cholesterol.Methods:Forty-six diabetic patients were randomly assigned to either fresh garlic alone (≈2 grams/day), or fresh garlic in combination with glibenclamide taken on an empty stomach every morning for a month. Serum blood glucose, cholesterol and blood pressure were measured before starting treatment and after the end of the treatment period.Results: Fresh garlic alone was able to decrease the mean serum cholesterol levels by 26 mg/dl (84% of the original base values), while the combination of fresh garlic and glibenclamide produced a 28 mg/dl decrease in the mean serum cholesterol (85% of the original base values). Fresh garlic alone was able as well to decrease the mean blood glucose levels by 20 mg/dl (85% of the original base values), while the combination of fresh garlic and glibenclamide produced a 60 mg/dl decrease in the serum glucose levels (72% of the original base values). Neither treatment had a significant effect on the mean systolic or diastolic blood pressures after 30 days of treatment.Conclusion: Administration of fresh garlic every morning for a month significantly reduced the blood cholesterol and fasting blood glucose levels in diabetic patients. Thus administering dietary fresh garlic daily to diabetic patients might have cardio-protective effects on diabetic patients

Antibiotics Consumption in the Eastern Region of Libya 2012-2013

Background: Drug utilization studies conducted in Libya during the period 1991-2013, have pointed out that there is an irrational use of antibiotics as a common practice that costs the health system more than 7.7 million Libyan Dinars / year. The aim of this study is to assess the trend of antimicrobial consumption in the Eastern region of Libya during 2012 ­ 2013.Methods: Antimicrobial consumption data from the years 2012 and 2013 were obtained mainly from Benghazi office, Medical Supply Organization (MSO; the only official drug-importing body in Libya). This study is concerned with antibiotics imported only to the Eastern region of Libya, population of which representing approximately 35% of total Libyan population. The WHO, Anatomical-Therapeutic-Chemical (ATC) classification and the Defined Daily Dose (DDD) methodology were used to calculate antibiotic consumption. The total antimicrobial consumption data were calculated as DDD/1000 inhabitants/day.Results: Total utilization of antibiotics decreased dramatically from 15.47 DDD/1000 inhabitants/day in 2012 to 4.30 DDD/1000 inhabitants/day in 2013 which in turn shows a significant decline compared to 41.72 DDD/1000 inhabitants/day during the period 1991-1993. Consumption of penicillins decreased from 19.902 DDD/1000 inhabitants/day during 1991-1993 to 1.896 DDD/1000 inhabitants/day during 2012-2013 with pattern of amoxicillin/clavulanic acid consumption which equals 3 times ampicillin consumption and is the highest compared to all penicillins. This was accompanied by a prominent increase in consumption of amphenicols and fusidic acid during 2012-2013, noting that fusidic acid consumption was the highest among all antibiotics. Conclusion: MSO since 2011 (post 17th February, 2011 revolution) lost its control over importing medicine due to receiving many drugs, as donations from different international sources without acceptable levels of coordination. This has been reflected on drug purchasing policy of MSO during 2013, which failed to regain the previously accepted level of DDD/1000 inhabitants/day for antibiotics consumption. The decreased consumption of penicillins together with increased consumption of amphenicols and fusidic acid complies with the pattern of antibiotic resistance reported previously in Libya. Similar studies should be conducted to evaluate national drug consumption under normal conditions, to be compared with regional and international data

Pattern of ocular trauma in Benghazi eye hospital, Benghazi, Libya

Background: This study was conducted to determine the pattern of ocular trauma in Benghazi- Libya Methods: All cases of ocular trauma admitted to Benghazi eye hospital from January 2011 to August 2012 were retrospectively reviewed for open- or closed-globe injury (OGI or CGI). Data extracted included age, sex, residence, initial and final visual acuity (VA), cause and treatment of injury. The injuries were classified by Ocular Trauma Classification System.Results: Out of the 805 patients, there were 540 patients (67.0%) with Closed Globe Injury and 254 patients (31.5%) with Open Globe Injury and 11 patients (1.3%) with mixed trauma. Conclusion: This analysis shows a pattern of eye injury largely similar to reports from other parts of the world. Eye injury affected mainly younger age groups and road traffic accidents were the most common cause

The prevalence of Temporomandibular disorders among a group of Libyan dental students

Background: It has been reported that Tempro-Mandibular-disorders (TMD) is the most common orofacial pain source of non-dental origin. The aim of this cross-sectional observational study is to explore the prevalence of signs and symptoms of TMD among a group of dental students in Benghazi-Libya.Methods: The examined group comprised 100 students [17 males and 83 females; mean age: 24.8±2.23 years. The assessment was undertaken following Helkimo's measures. The prevalence and severity of TMD was determined using a self-reported anamnestic questionnaire and clinical examination. Descriptive statistics was employed to explore the frequencies of the examined variables. Linear correlation coefficient was conducted between the reported symptoms and recorded signs and between the reported symptoms and the clinical dysfunction scores (CDS). The level of significance was set at P<0.05.Results: A total of 37% of the students reported some level of TMD symptoms [32% mild (Ai1); 5% severe (AiII)]. On the other hand, majority of the students (93%) demonstrated a range of TMD signs [76% mild (DiI); 17% moderate (DiII)].Although linear correlation coefficient between the reported symptoms (Ai) and the recorded signs (Di) (r=0.32) and between the reported symptoms (Ai) and the CDS (r=0.37) were low, they were statistically significant (P<0.05.Conclusion: Mild to moderate prevalence of TMD appears to exist among Libyan dental students

Antimicrobial resistance activity and molecular characterization of methicillin-resistant staphylococci isolates in Tripoli Central Hospital, Libya

Background: Nosocomial infections caused by methicillin-resistant Staphylococci could lead to increased morbidity and mortality, but little is known about the prevalence of infections with these organisms in healthcare facilities and in the community in Tripoli. This study investigated the in vitro susceptibility of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagulase negative staphylococci (MRCNS) to antimicrobial agents, and determined the molecular characteristics of MRSA.Methods: This is a retrospective observational study aiming at determining the prevalence and antibiotic resistance pattern of (MRSA) and (MRCNS) isolated from non-duplicated clinical specimens in Tripoli Central Hospital (TCH) between June 2013 and June 2014. Isolates were identified using standard laboratory procedures. Antimicrobial susceptibility tests were carried out by disk diffusion method and automated systems. DNA of the MRSA isolates was used for PCR to determine the molecular analysis.Results: 218 isolates of Staphylococci were obtained, 71.6% were coagulase positive staphylococci (CPS) and 28.4% were coagulase negative staphylococci (CNS). 39.7% of CPS were MRSA, while 75.8% of CNS were MRCNS. The rates of hospital-acquired MRSA (HA-MRSA) and community-acquired MRSA (CA-MRSA) among MRSA isolates were 61.3% and 38.7% respectively. A similar trend was detected among MRCNS isolates, where 74.5% were HA-MRCNS and 25.5% were CA-MRCNS. All the MRSA and MRCNS isolates were susceptible (100%) to vancomycin, tigecycline, linezolid, quinupristin/dalfopristin, daptomycin and moxifloxacin. Generally, hospital-acquired strains showed higher resistance rates than community-acquired ones to the most commonly tested non-beta-lactam antibiotics. 35.5% of all staphylococcal isolates exhibited mecA+ gene and 12.9% expressed mecC+. Meanwhile, 38.7% of MRSA isolates harbored both mecA and mecC. However, 12.9% of MSSA isolates were negative for both mecA and mecC. The mecA gene was detectable in 59.1% and 40.9 % of HA-MRSA and CA-MRSA isolates respectively.Conclusion: Hospital-acquired MRSA and MRCNS isolates had higher resistance rates to non-beta lactam antimicrobial drugs than the respective community-acquired isolates. This was shown by early detection of mecC gene among MRSA isolates

A descriptive retrospective study on children with newly diagnosed nephrotic syndrome presented to Tripoli Children Hospital during the period between Jan. to Dec. 2014

Introduction: Nephrotic syndrome is a clinical picture characterized by severe proteinuria, hypoalbuminemia, edema and hypercholesterolemia. A retrospective study was carried out in order to describe disease pattern in newly diagnosed nephrotic syndrome of children admitted to Tripoli children hospital during the year 2014.Methods: The medical data of 56 patients aged between 1 year and 11 years diagnosed with idiopathic nephrotic syndrome were analysed using SPSS software. The data included gender differences, sensitivity to steroid therapy, relapses during six months of follow up and the effect of variable factors such as family history, hypertension, hematuria, serum urea on the degree of relapse.Results: Out of 56 patients with newly diagnosed nephrotic syndrome (NS), 60.7% were boys and 39.3% were girls, with a mean age 4.2±2.2 years. Age was related significantly to the response to steroid therapy, where 79.5% of patients aged between 2-8 years (group 1) had steroid sensitive nephrotic syndrome (SSNS) compared with only 41.7% of patients aged less than 2 years or more than 8 years (group 2) (P<0.001). Although girls relapsed more than boys (70.5% versus 57.1%) during six months of therapy, this difference was not statistically significant. Similarly, no other factors measured such as family history of NS, hypertension, hematuria, serum complement and urea had any effect on the percentage of relapse in patients with newly diagnosed NS. Conclusion: NS is one of the commonest reasons for admission to nephrology ward. It is more common in boys than girls. The age at presentation related significantly to the response to steroidal therapy. Regarding relapses, girls seems to relapse more frequent than boys and relapses was seen more in age group 1 than group 2, however, these differences were not significant. Other factors studied seems to have no effect on the relapse rate of children with newly diagnosed NS

Knowledge towards breast cancer among Libyan women in Tripoli

Introduction: Breast cancer in women is the commonest type of cancer worldwide. However, in Libya, ordinary systematic screening for breast cancer is neglected.Aim: The present study was aimed to evaluate the women's knowledge towards breast cancer and its risk factors.Methods: A cross-sectional survey, using self-administered questionnaire and face-to-face interviews was conducted at different places in Tripoli city along a period of nine months, from April-December 2013.Results: The mean age (±SD) of the participated women was 48±5 years and out of 284 contributors 84.5% were married. One hundred and eighty women (63.4%) stated that long-term use of contraceptive pills (> 5 years) increases the incidence rate of breast cancer. Besides, more than half of participants (157 women) specified that breast cancer is treated by surgery, chemotherapy and radiotherapy. However, although 50.7% of women reported that mammography and ultrasound are used for early detection, more than 60% of women believed that mammogram can cause cancer. In addition, our data demonstrate that increased knowledge was associated with women who know how to do self-examination and living in urban area.Conclusion: Our findings demonstrate that Libyan women have acceptable level of knowledge regarding breast cancer. However, improvement of the health systems and awareness regarding breast cancer is needed

Studies and evaluation of compressed microspheres

This work was aimed at the use of dissolution testing and similarity factor to assess the level of damage taken by active drug microspheres during compression in tablet dosage form. To achieve that, combinations of suitable excipients were used to protect drug microspheres during compression. The excipients were used in the form of powders, granules or placebo pellets prepared by extrusion-spheronization technology. The excipients were evaluated alone, in combinations and post-compression into compacts. Preliminary experiments included density, hardness, friability and disintegration on all of the selected excipients. Based on such experiments it was found that the flowability of combination powders was more acceptable than individual excipients. Two combinations of microcrystalline -starch and microcrystalline cellulose -calcium carbonate granules were selected to be compressed with active ketoprofen pellets. In all the combinations used there was a significant amount of damage to drug pellets. The kinetics of drug release appears to follow the zero-order rate and the rate remained unchanged even when a significant degree of damage to pellets occur. It was found that a high level of excipients is required in order to prepare microspheres as a rapid disintegrating tablet

Investigating the importance of haemoglobin measurement for selection of blood donors in Libya

In Libya, haemoglobin estimation is not used routinely to assess the fitness of blood donors. We examined the importance of including this parameter in donor selection. Venous blood samples were collected from the bleed line at the end of the donation process from 1339 healthy adult male blood donors, aged 18­60 years, in Al-Jala Women Hospital in Tripoli, Libya. Haemoglobin concentration was measured using an automated haematology analyzer. The main donor age categories were 21-30 and 31-40 years (49.5% and 37%, respectively). Blood donation was mainly a replacement donation. The mean ±2SD range for haemoglobin was 10.8­17.0 g/dl. 27.2% of the donors had haemoglobin concentration of less than 13 g/dl, 16.9% of them had less than 12.5 g/dl and 1.9% had less than 10.8.5 g/dl.Our results suggest that it is important to include haemoglobin estimation as a routine procedure in selection of blood donors

Manipulation of nitric oxide in an animal model of acute liver injury. The impact on liver and intestinal function

Background: Nitric oxide may have a protective effect on the liver during endotoxemia and chronic inflammation. There is evidence that it maintains liver and intestinal tissue integrity during inflammatory processes. We evaluated the impact of altering nitric oxide release on acute liver injury; the associated gut injury and bacterial translocation; at different time intervals. Methods: An acute rat liver injury model induced by D-galactosamine was used. Sprague Dawley rats were divided into four main groups: normal control; acute liver injury control; acute liver injury + N-nitro-L-arginine methyl ester (L-NAME); acute liver injury + L-NAME + L-arginine. Each group was divided into three subgroups according to the different time intervals (6; 12; 24 hours) after the induction of the liver injury. Liver enzymes and bilirubin were evaluated; as well as bacterial translocation; cecal and colonic microflora; and histological study of liver; ileum and cecum. Results:Liver enzymes increased significantly at all time intervals in acute liver injury + L-NAME compared to liver injury control groups. Bacterial translocation increased significantly in liver injury + L-NAME groups; at 6 hours to the liver; at 12 hours to the liver and mesenteric lymph nodes (MLNs); and at 24 hours to arterial and portal blood; liver and MLNS. Inhibition of nitric oxide increased significantly the Enterobacteriaceae count in cecum compared to normal and liver injury control groups. The G-negative anaerobes increased significantly in the colon compared to the liver injury control group. Conclusion: Inhibition of nitric oxide in an acute liver injury model potentiates the liver injury as evidenced by increased appearance of hepatocellular necrosis and elevated liver enzymes and bilirubin. It increases the Enterobacteriaceae in both cecum and colon and G-negative anaerobes in the colon. It also increases bacterial translocation to extra-intestinal sites. The increased bacterial translocation could be one of the mechanisms potentiating liver injury and nitric oxide may be pathophysiologically involved. Further studies are required to confirm this hypothesis

PubMed Medical Publications From Libya

Medical research and publications are the back-bone for advancing the medical field. We identified the PubMed medical publications that are affiliated with Libya to shed some light on the contribution of this country's medical community to the PubMed database. All publications affiliated with Libya in the PubMed were counted over a five year period ending December 2006. We also used the same method to obtain data on the PubMed medical publications from Tunisia; Morocco and Yemen. Tunisia had the largest number of PubMed publications among the studied countries: 20.4 publications per million population per year and 7.2 publications per year per one billion US$ GDP. Libya had much fewer publications: 2.4 publications per million population per year and 0.4 publications per one billion US$ GDP. The citation frequency for Libyan published research was very low compared to Tunisian and Moroccan related research. Conclusion: This preliminary analysis shows that medical research output in Libya is about twenty times less than in other countries with similar backgrounds; and that it needs to be enhanced

Effects of calcium channel blockers on antidepressant action of Alprazolam and Imipramine

Alprazolam is effective as an anxiolytic and in the adjunct treatment of depression. In this study; the effects of calcium channel antagonists on the antidepressant action of alprazolam and imipramine were investigated. A forced swimming maze was used to study behavioral despair in albino mice. Mice were divided into nine groups (n = 7 per group). One group received a single dose of 1Tween 80; two groups each received a single dose of the antidepressant alone (alprazolam or imipramine); two groups each received a single dose of the calcium channel blocker (nifedipine or verapamil); four groups each received a single dose of the calcium channel blocker followed by a single dose of the antidepressant (with same doses used for either in the previous four groups). Drug administration was performed concurrently on the nine groups. Our data confirmed the antidepressant action of alprazolam and imipramine. Both nifedipine and verapamil produced a significant antidepressant effect (delay the onset of immobility) when administered separately. Verapamil augmented the antidepressant effects of alprazolam and imipramine (additive antidepressant effect). This may be due to the possibility that verapamil might have antidepressant-like effect through different mechanism. Nifedipine and imipramine combined led to a delay in the onset of immobility greater than their single use but less than the sum of their independent administration. This may be due to the fact that nifedipine on its own might act as an antidepressant but blocks one imipramine mechanism that depends on L-type calcium channel activation. Combining nifedipine with alprazolam produced additional antidepressant effects; which indicates that they exert antidepressant effects through different mechanisms