Multinodular goiter with a retropharyngeal extension: A report of two cases and literature review.

Multinodular goiter (MNG) is a chronic benign nodular enlargement of the thyroid gland. It presents as an anterior painless neck mass, potentially progressing to exert pressure on the trachea and esophagus and giving rise to compressive symptoms. MNG is a common thyroid gland disorder; however, retropharyngeal goiter is considered rare with few reported cases. We report the cases of two patients who presented to our institution with MNG with retropharyngeal extension: a 62-year-old female patient who presented with a progressive anterior neck mass with dilated neck veins; and a 49-year-old male who presented with a painless anterior neck mass. Both patients successfully underwent total thyroidectomy with an uneventful postoperative recovery. The clinical presentation of MNG with retropharyngeal extension varies with patients; hence, a high index of suspicion is of the utmost significance. While the retropharyngeal extension does not cause compressive symptoms, it should raise the suspicion of a large retrosternal component.

Prevalence of Classical Extraintestinal Manifestations among Inflammatory Bowel Disease Patients in Saudi Arabia: A Single Tertiary Center Experience.

Background: Patients with inflammatory bowel disease (IBD) may also experience extraintestinal manifestations (EIMs), which can affect various organ systems, and their occurrence is based on disease activity. Objectives: To determine the prevalence of EIMs and their most common types among IBD patients from Saudi Arabia. Materials and Methods: This retrospective study included all IBD patients aged 14-80 years who visited the Gastroenterology and Hepatology clinics at King Fahad Medical City, Riyadh, between February 2017 and December 2022. The collected data included demographic characteristics, disease characteristics, EIMs, and treatment. Results: The study included 578 IBD patients, of which 65 (11.2%) had at least one EIM, with primary sclerosing cholangitis (46.2%) and sacroiliitis (16.9%) being the most common. Patients with ulcerative colitis were more likely to have EIMs than those with Crohn's disease (15.1% vs. 9%; P = 0.026). Patients with ileocolonic (L3) Crohn's disease reported a higher prevalence of EIMs (7.5%) than those with other disease locations (P = 0.012), while in patients with ulcerative colitis, those with extensive colitis (E3) reported higher prevalence of EIMs (19.2%) (P = 0.001). Patients receiving 6 MP had a significantly high prevalence of EIMs (P = 0.014). Conclusion: The prevalence of extraintestinal manifestations among IBD patients in Saudi Arabia is 11.2%. These findings suggest the need for clinicians to screen for EIMs and manage them early. Further research is needed to understand the mechanisms underlying EIMs for the development of more effective treatments.

Key Performance Indicators: A Framework for Allied Healthcare Educational Institutions.

Background: Performance evaluation in the allied healthcare education sector is complex, making it essential for policymakers and managers to approach it comprehensively and thoughtfully to understand their performance. Hence, the development and monitoring of Key Performance Indicators (KPIs) in this domain must be considered one of the key priorities for the policymakers in AHIs. Aim: This study aims to develop a framework for the AHIs to extract and profile the indicators, measure, and report the results appropriately. Methods: The authors adopted a general review of the literature approach to study the primary goals of the institutional KPI framework, emphasizing the need for benchmarking while implementing KPIs and how to track performance using a KPI dashboard. Results: The study provides the scope, relevant KPI categories, and a list of KPIs for evaluating the effectiveness of allied healthcare programs. The study findings also emphasized the need for benchmarking the KPIs and establishing a KPI dashboard while measuring and monitoring performance. Conclusion: KPIs are considered an invaluable tool that contributes immensely to the performance monitoring process of AHIs, irrespective of the specialties. This helps to identify and guide AHIs for developing KPIs and the associated minimum data set to measure organizational performance and monitor the quality of teaching and learning. In addition, the KPI framework reported in this study is a tool to assist performance monitoring that can subsequently contribute to the overall quality of AHIs.

Psychometric properties and development of a structured questionnaire to assess the perception, attitude, and job satisfaction among respiratory therapists.

Background: Over the past ten years, significant transformations have occurred in the healthcare landscape, presenting respiratory therapists (RTs) with a mix of challenges and opportunities. Hence, their perceptions about career progression and job satisfaction will be critical factor in determining the recruitment and retention of RTs. However, there are no studies in the literature that comprehensively assessed these aspects using a reliable and valid measure specific to RTs. Our objective was to develop and psychometrically test a Standardized Questionnaire (SQ) for evaluating RT's overall job satisfaction. Methods: Following consultations with experts and interviews conducted with RTs, a preliminary questionnaire was devised for the purpose of exploratory factor analysis (EFA). The 49 items of the Structured Questionnaire (SQ) were used for verification of the theorized factor structure and content validity using a confirmatory factor analysis (CFA). Principal Component Analysis (PCA), Structural Equation Modeling (SEM), and Confirmatory Factor Analysis (CFA) for the global fit were done. Cronbach's alpha was performed to estimate the internal consistency. The samples of RTs were collected from India between August 2021 and January 2022. Results: A convenience sample comprising 409 respiratory therapists (RTs) employed in India participated in the survey conducted from June 2021 to January 2022. The exploratory factor analysis revealed three factors that explained 61.2 % of the total variance. The confirmatory factor analysis yielded a 3-factor structure (X2/df = 4.4, p < 0.02, standardized root-mean-square residual = 0.05, goodness of fit index = 0.94, comparative fit index = 0.98). The Cronbach's alpha was 0.94 for the total scale. Conclusions: Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) are becoming more prevalent, especially in the development and psychometric evaluation of instruments. This Structured Questionnaire is a reliable and valid tool that has utility for assessing perceptions, satisfaction, and attitude among Respiratory Therapists and for making comparisons of similar psychometric measures.

The long-term effects of COVID-19 on pulmonary status and quality of life.

Background: Few studies have looked at how SARS-CoV-2 affects pulmonary function, exercise capacity, and health-related quality of life over time. The purpose of this study was to evaluate these characteristics in post COVID-19 subjects 1 year after recovery. Methods: The study included two groups. The case group included post COVID-19 subjects who had recovered after a year, and the control group included healthy participants who had never tested positive for COVID-19. Results: The study screened 90 participants, 42 of whom met the eligibility criteria. The findings revealed that the majority of post COVID-19 subjects had relatively normal lung function 1-year post-recovery. A significant reduction in DLCO (B/P%) was observed in the case group vs. control. The exercise capacity test revealed a clinically significant difference in distance walked and a significant difference in the dyspnea post-walk test in the case group compared to the control group. The case group's health-related quality of life domain scores were significantly affected in terms of energy/fatigue, general health, and physical function. Conclusions: The post COVID-19 subjects were shown to have well-preserved lung function after 1 year. However, some degree of impairment in diffusion capacity, exercise capacity, and health-related quality of life remained.

Prevalence and Risk Factors of Cytomegalovirus Colitis in Inflammatory Bowel Disease Patients in Riyadh, Saudi Arabia: A Tertiary Center Experience.

Background: Patients with inflammatory bowel disease (IBD) are at a higher risk of cytomegalovirus (CMV) colitis because of their immunocompromised status. There are no studies from Saudi Arabia regarding the prevalence of CMV colitis in patients with IBD. Objective: To determine the prevalence, characteristics, and risk factors of CMV colitis in patients with IBD in Riyadh, Saudi Arabia. Materials and Methods: This retrospective study included patients with a confirmed diagnosis of IBD (aged 14-75 years) who were followed up at King Fahad Medical City, a referral care center in Riyadh, between January 2016 and December 2021; patients with indeterminate colitis or incomplete medical records were excluded. Results: A total of 341 patients with IBD were included, of which 236 (72.2%) had Crohn's disease (CD) and 105 (27.8%) had ulcerative colitis (UC). Qualitative CMV PCR was done for 192 patients (60 UC and 132 CD patients), of which 14 patients were positive for CMV colitis (7.3%), and all positive CMV colitis cases were among UC patients (23.3%). However, the hematoxylin and eosin (H and E) stain and immunohistochemistry were negative for all patients. Most patients with CMV colitis were on steroids (71.4%), had at least one flare-up (64.3%), and were on biologic treatment (71.4%). Significant predictors of CMV colitis were hemoglobin (OR: 0.7; 95% CI: 0.51-0.96), albumin (OR: 0.88; 95% CI: 0.78-0.98), and C-reactive protein (OR: 1.03; 95% CI: 1.01-1.06) levels. Conclusion: This study found that the prevalence of CMV colitis was 7.3% among patients with IBD, and no case was diagnosed in patients with CD. In addition, as all cases diagnosed using qualitative CMV PCR were negative on H and E stain and immunohistochemistry, there is need for large-scale studies to improve the diagnosis of CMV colitis.

Pancreatitis Prevention in Tabuk City, Kingdom of Saudi Arabia: Evaluating Public Knowledge and Raising Awareness of Risk Factors and Symptoms.

INTRODUCTION: Pancreatitis is an inflammation of the pancreas. The pancreas is a flat, elongated gland situated in the upper abdomen, beyond the stomach. It produces digestive enzymes and hormones that regulate glucose absorption in the body. Pancreatitis can be acute, developing rapidly and lasting for several days, or chronic, persisting over an extended period and affecting specific individuals. While treatment can improve mild cases of pancreatitis, severe cases can be fatal. METHOD: This study utilizes a cross-sectional survey design with 549 participants, allowing data collection from a representative sample of Tabuk City's adult population. RESULTS: The participants' knowledge about the risk factors and symptoms of pancreatitis was inadequate. Among those who did not receive any information about pancreatitis and its risk factors, the count was 352 (64.1%). On the other hand, there was increased awareness of pancreatitis and its risk factors, which would lead to early detection and prevention. A total of 483 participants (88%) expressed adequate agreement, and 305 participants (55.6%) demonstrated an adequate response regarding seeking medical attention if they experienced any symptoms of pancreatitis. CONCLUSION: Our findings revealed a lack of knowledge about the risk factors and symptoms of pancreatitis. Furthermore, there was inadequate awareness regarding governmental initiatives or programs that support access to pancreatitis knowledge and awareness in Tabuk City.

Perspectives, practices, and challenges of online teaching during COVID-19 pandemic: A multinational survey.

The result of the movement restrictions during the COVID-19 pandemic was an impromptu and abrupt switch from in-person to online teaching. Most focus has been on the perception and experience of students during the process. The aim of this international survey is to assess staffs' perspectives and challenges of online teaching during the COVID-19 lockdown. Cross-sectional research using a validated online survey was carried out in seven countries (Brazil, Saudi Arabia, Jordan, Indonesia, India, the United Kingdom, and Egypt) between the months of December 2021 and August 2022, to explore the status of online teaching among faculty members during the COVID-19 pandemic. Variables and response are presented as percentages while logistic regression was used to assess the factors that predict levels of satisfaction and the challenges associated with online instruction. A total of 721 response were received from mainly male (53%) staffs. Most respondents are from Brazil (59%), hold a Doctorate degree (70%) and have over 10 years of working experience (62%). Although, 67% and 79% have relevant tools and received training for online teaching respectively, 44% report that online teaching required more preparation time than face-to-face. Although 41% of respondents were uncertain about the outcome of online teaching, 49% were satisfied with the process. Also, poor internet bandwidth (51%), inability to track students' engagement (18%) and Lack of technical skills (11.5%) were the three main observed limitations. Having little or no prior experience of online teaching before the COVID-19 pandemic [OR, 1.58 (95% CI, 1.35-1.85)], and not supporting the move to online teaching mode [OR, 0.56 (95% CI,0.48-0.64)] were two main factors independently linked with dissatisfaction with online teaching. While staffs who support the move to online teaching were twice likely to report no barriers [OR, 2.15 (95% CI, 1.61-2.86)]. Although, relevant tools and training were provided to support the move to online teaching during COVID-19 lockdown, barriers such as poor internet bandwidth, inability to track students' engagement and lack of technical skills were main limitations observed internationally by teaching staffs. Addressing these barriers should be the focus of higher education institution in preparation for future disruptions to traditional teaching modes.

Successful Management of a Symptomatic Vallecular Cyst in an Adult: A Case Report.

In adults, vallecular cysts are usually asymptomatic but can present with respiratory and gastrointestinal manifestations. A 45-year-old man presented with a four-month progressive history of dysphonia, dysphagia to solid, snoring, choking, apnea, and aspiration. On examination, the patient was vitally stable with no remarkable local and physical examination. Flexible nasoendoscopy, computer tomography, and subsequent micro-laryngoscopy revealed a non-pulsating, non-congested 3 x 2 cm cyst obscuring vocal cord visualization. The cyst was removed completely by cold and hot techniques and was sent for biopsy. This case report presents the successful management of a symptomatic vallecular cyst through electrocautery.

A nationwide survey of public COPD knowledge and awareness in Saudi Arabia: A population-based survey of 15,000 adults.

BACKGROUND: There is a concerning lack of representative data on chronic obstructive pulmonary disease (COPD) awareness in Saudi Arabia, and a significant proportion of the population is vulnerable to developing a smoking habit, which is a major risk factor for the disease. METHODS: Population-Based Survey of 15,000 people was conducted to assess the public knowledge and awareness of COPD across Saudi Arabia from October 2022 to March 2023. RESULTS: A total of 15002 responders completed the survey, with a completion rate of 82%. The majority 10314 (69%) were 18-30 year and 6112 (41%) had high school education. The most common comorbidities among the responders were depression (7.67%); hypertension (6%); diabetes (5.77%) and Chronic Lung Disease (4.12%). The most common symptoms were dyspnea (17.80%); chest tightness (14.09%) and sputum (11.19%). Among those who complains of any symptoms, only 16.44% had consulted their doctor. Around 14.16% were diagnosed with a respiratory disease and only 15.56% had performed pulmonary function test (PFT). The prevalence of smoking history was 15.16%, in which current smokers were 9.09%. About 48% of smokers used cigarette, 25% used waterpipe and around 27% were E-cigarette users. About 77% of the total sample have never heard about COPD. Majority of current smokers (73.5%; 1002), ex-smokers (68%; 619), and non-smokers (77.9%; 9911) are unaware of COPD, p value <0.001. Seventy five percent (1028) of the current smokers and 70% (633) of the ex-smokers have never performed PFT, p value <0.001. Male, younger age (18-30 years), higher education, family history of respiratory diseases, previous diagnosis of respiratory disease, previous PFT, and being an ex-smokers increases the odds of COPD awareness, p-value <0.05. CONCLUSION: There is a significantly low awareness about COPD in Saudi Arabia, especially among smokers. A nationwide approach must include targeted public awareness campaigns, continued healthcare professional education, community-based activities encouraging diagnosis and early detection, advice on smoking cessation and lifestyle changes, as well as coordinated national COPD screening programs.

Impact of Smoking Status and Nicotine Dependence on Academic Performance of Health Sciences Students.

Background: Smoking behavior has been associated with poor academic performance among adult students worldwide. However, the detrimental effect of nicotine dependence on several students' academic achievement indicators is still unclear. This study aims to assess the impact of smoking status and nicotine dependence on grade point average (GPA), absenteeism rate and academic warnings among undergraduate health sciences students in Saudi Arabia. Methods: A validated cross-sectional survey was conducted, in which, participants responded to questions evaluated cigarette consumption, urge to consume and dependency, learning performance, days of absentees, and academic warnings. Results: A total of 501 students from different health specialties have completed the survey. Of whom, 66% were male, 95% ranging between the age of 18-30 years old, and 81% reported no health issues or chronic diseases. Current smokers estimated to be 30% of the respondents, of which 36% revealed smoking history of 2-3 years. The prevalence of nicotine dependency (high to extremely high) was 50%. Overall, smokers had significantly lower GPA, higher absenteeism rate, and higher number of academic warnings when compared to nonsmokers (p<0.001). Heavy smokers demonstrated significantly less GPA (p=0.036), higher days of absences (p=0.017), and more academic warnings (p=0.021) compared to light smokers. The linear regression model indicated a significant association between smoking history (increased pack-per-year) and poor GPA (p=0.01) and increased number of academic warning last semester (p=0.01), while increased cigarette consumption was substantially linked with higher academic warnings (p=0.002), lower GPA (p=0.01), and higher absenteeism rate for last semester (p=0.01). Conclusion: Smoking status and nicotine dependence were predictive of worsening academic performance, including lower GPA, higher absenteeism rate and academic warnings. In addition, there is a substantial and unfavorable dose-response association between smoking history and cigarette consumption with impaired academic performance indicators.

Discovery of Anti-CD47 Peptides as Innate Immune Checkpoint Inhibitors.

Cancer immunotherapy targeting adaptive immune cells has been attracting considerable interest due to its great success in treating multiple cancers. Recently, there is also increasing interest in agents that can stimulate innate immune cell activities. Immune checkpoint inhibitors targeting innate immune cells can block inhibitory interactions ('don't eat me' signals) between tumor cells and phagocytes. CD47 is a transmembrane protein overexpressed in various cancers and acts as a potent 'do not eat me' signal that contributes to the immune evasion of cancer cells. Anti-CD47 peptides that can bind to CD47 and block CD47/SIRPα interaction were discovered using a novel phage display biopanning strategy. Anti-CD47 peptides enhanced the macrophage-mediated phagocytosis of NCI-H82 tumor cells in vitro. Unlike anti-CD47 antibodies, these peptides do not induce the agglutination of RBCs. Moreover, anti-CD47 peptides exhibit high specificity for MC-38 cancer cells expressing CD47. CMP-22 peptide showed the ability to increase the antitumor activity of doxorubicin and extends the survival of CT26 tumor-bearing mice. The discovered anti-CD47 peptides can be considered potential candidates for cancer immunotherapy by blocking the CD47/SIRPα interaction, especially in combination with chemotherapy, to elicit synergistic effects.

Routine Application of Lung Ultrasonography in Respiratory Care: Knowledge, Perceptions, and Barriers to Instigate.

Background: Lung Ultrasound (LUS) had proved to be beneficial in detecting respiratory disorders at the bedside. Understanding the important role of Respiratory Therapists (RTs) in the critical care, we aimed to assess their knowledge, perceived relevance of LUS to clinical practice, current skill gaps, and barriers to practice. Methods: A cross-sectional, nationwide survey conducted among the RTs working in the Kingdom of Saudi Arabia. The validated questionnaire included 4 sections; the demographics, knowledge and perceptions, applicability and self-reported proficiency, and barriers to the use of LUS by RTs. Results: A total of 256 RTs across different regions of Saudi Arabia participated in this survey. 71.9% of them were males, and 46.1% of the participants were having <5 years of working experience. Only (18.1%) of the participants used LUS in their clinical practice, and (43%) of them had never received any training. 66% of the participants perceived LUS as an effective tool in the RT practice and immensely valuable in their daily practice (70%). A large proportion of RTs perceived LUS to be ineffective in calculating the lung score (50.4%), assessing the diaphragm (40.2%), and detecting pulmonary edema (38.3%). Calculating lung score has a lower mean score of 2.55 on both skills, and identifying its applicability to clinical practice with a mean score of 2.71 than other indications. Lack of training and curriculum (154/256; 60.2%) remains the top barrier that prevented RTs from using LUS in their clinical practice. Conclusion: While many RTs in Saudi Arabia perceived LUS as an effective tool in the RT practice, considerable competence gap exist, indicating the need for LUS training. There is a need for incorporating LUS into the curriculum of RT schools and promoting competency-based training for the current RT workforce to help improve patient care.

Needs Assessment for the Establishment of Master's Degree Programs in Respiratory Care in the Kingdom of Saudi Arabia.

Background: Despite recent advancements in the respiratory care (RC) profession, no single institution in the Kingdom of Saudi Arabia (KSA) offers a master's degree program in RC. Methods: A nationwide and validated survey was used to explore the current needs and interests in establishing RC master's degree programs in the KSA. The process included representatives from the healthcare industry, universities, and professional societies. Results: A total of 1250 stakeholders across the KSA completed the survey. The sample includes 722 (58%) males, 504 (40%) respiratory therapists, 547 (44%) students, 138 (11%) leaders, and 61 (5%) were academic respondents. Most respondents were from Central 491 (39%) and Eastern 307 (25%) regions, with 1003 (80%) of the total sample worked or studied in governmental sectors. A total of 574 (82%) of the leaders and RTs had Bachelor degree and 430 (61%) of them had 1-5 years working experience. According to 80% of the employers and employees, only 0-5% of the RTs in their organization had a master's degree. The calculated mean % of the agreement (agree/strongly agree) on the needs was 83% in all needs' assessment items, which shows a great support for establishing a master's in RC to meet the personal, professional and society needs. The mean % of the agreement for the level of interests among all participants was 86%, indicating a great level of interests in establishing a master degree in RC. The agreement % on the needs assessment and level of interests in establishing a master degree in RC in KSA were ≥80% in each stakeholder group. Conclusion: There are obvious needs and interests in establishing master's degree programs in RC in the KSA. A master's degree in RC should be established to address the growing needs for advanced RC services throughout the nation and enhance RC research.

Discovery of Cyclic Peptide Inhibitors Targeting PD-L1 for Cancer Immunotherapy.

Blockade of the interaction between programmed cell death ligand-1 (PD-L1) and its receptor PD-1 has shown great success in cancer immunotherapy. Peptides possess unique characteristics that give them significant advantages as immune checkpoint inhibitors. However, unfavorable physicochemical properties and proteolytic stability profiles limit the translation of bioactive peptides as therapeutic agents. Studies have revealed that cyclization improves the biological activity and stability of linear peptides. In this study, we report the use of macrocyclization scanning for the discovery of cyclic anti-PD-L1 peptides with improved bioactivity. The cyclic peptides demonstrated up to a 34-fold improvement in the PD-1/PD-L1 blocking activity and significant in vivo anti-tumor activity. Our results demonstrate that macrocyclization scanning is an effective way to improve the serum stability and bioactivity of the anti-PD-L1 linear peptide. This strategy can be employed in the optimization of other bioactive peptides, particularly those for protein-protein interaction modulation.

Recovery of Cranial Nerve Deficits in Patients Presenting with Pituitary Apoplexy: A Case Series.

Background Pituitary apoplexy (PA) is a rare complication of pituitary tumors that can present with a myriad of symptoms, including sudden onset cranial nerve deficits. After patient stabilization and hormone replacement, surgical decompression is often recommended. The timing of surgical decompression remains controversial. In this case series, we describe our institutional experience pertaining to the cranial nerve recovery in patients who underwent endoscopic endonasal transsphenoidal (EETS) surgery for PA while evaluating outcome based on tumor stage using the suprasellar infrasellar parasellar anterior posterior (SIPAP) classification. Design Present study is a single-institution retrospective cohort. Methods A retrospective review of all EETS cases for pituitary tumor resection between November 2009 and August 2018. Queries of the hospital database were completed by trained personnel to identify cases of PA treated using the EETS approach. Baseline characteristics, tumor type, endocrine data, and SIPAP classification based on preoperative magnetic resonance imaging (MRI) and operation characteristics were extracted from medical records. Postoperative results were extracted for the duration of the follow-up period available for each patient. Results Fifteen cases of PA were identified. Patient follow-up period was a mean of 30 months. The cranial nerve deficits present at admission were visual deficit (33%); unilateral third nerve palsy (47%) and unilateral sixth nerve palsy (27%). No fourth nerve palsies were observed. Following EETS, 60% of patients with preoperative visual deficit had normal visual fields. For those with third and sixth nerve palsies preoperatively, 43 and 75%, respectively, had return to normal function postoperatively. SIPAP tumor characteristics were not related to postoperative cranial nerve recovery. Conclusion In this series of surgically treated patients with pituitary apoplexy, all cranial nerve deficits normalized or improved following surgery. The tumor SIPAP classification was not associated with patient outcome. Though in a small series, the presented results suggest surgical treatment is beneficial for these patients.

Ectopic Recurrence of Skull Base Chordoma after Proton Therapy.

BACKGROUND: Chordoma are rare tumors of the axial skeleton. The treatment gold standard is surgery, followed by particle radiotherapy. Total resection is usually not achievable in skull base chordoma (SBC) and high recurrence rates are reported. Ectopic recurrence as a first sign of treatment failure is considered rare. Favorable sites of these ectopic recurrences remain unknown. METHODS: Five out of 16 SBC patients treated with proton therapy and surgical resection developed ectopic recurrence as a first sign of treatment failure were critically analyzed regarding prior surgery, radiotherapy, and recurrences at follow-up imaging. RESULTS: Eighteen recurrences were defined in five patients. A total of 31 surgeries were performed for primary tumors and recurrences. Seventeen out of eighteen (94%) ectopic recurrences could be related to prior surgical tracts, outside the therapeutic radiation dose. Follow-up imaging showed that tumor recurrence was difficult to distinguish from radiation necrosis and anatomical changes due to surgery. CONCLUSIONS: In our cohort, we found uncommon ectopic recurrences in the surgical tract. Our theory is that these recurrences are due to microscopic tumor spill during surgery. These cells did not receive a therapeutic radiation dose. Advances in surgical possibilities and adjusted radiotherapy target volumes might improve local control and survival.

Clinical Practice and Barriers of Ventilatory Support Management in COVID-19 Patients in Saudi Arabia: A Survey of Respiratory Therapists.

OBJECTIVE: This study was conducted to determine the clinical practice and barriers of ventilatory support management in COVID-19 patients in Saudi Arabia among respiratory therapists. METHODS: A validated questionnaire comprising three parts was distributed to all critical care respiratory therapists registered with the Saudi Society for Respiratory Care through the official social networks. RESULTS: A total of 74 respiratory therapists completed the survey. The mean (±standard deviation) of intensive care unit beds was 67 ± 79. Clinical presentation (54%) and arterial blood gas (38%) were the two main diagnostic tools used to initiate ventilatory support. While protocols for the initiation of invasive mechanical ventilation (IMV; 81%) were widely available, participants had limited availability of protocols for the use of non-invasive ventilation (NIV; 34%) and high-flow nasal cannula (HFNC; 34%). In mild cases of COVID-19, most respondents used HFNC (57%), while IMV was mostly used in moderate (43%) and severe (93%) cases. Regular ventilator check was mostly done every 4 h (57%). BiPAP (47.3%) and full-face masks (45.9%) were the most used mode and interface, respectively, while pressure-regulated volume control (55.4%) and pressure control (27%) were the most used mechanical ventilation modes for COVID-19 patients. In terms of use of proning, 62% used it on IMV, while 26% reported using awake proning. Staff shortage (51.4%), personal protective equipment (PPE) shortage (51.4%), increased workload (45.9%), inadequate training (43.2%) and lack of available protocols and policies (37.8%) were the main barriers. CONCLUSION: Ventilatory support management of COVID-19 in Saudi Arabia was inconsistent with the global practice, lacked uniformity, and there was limited use of standard protocols/treatment guidelines. Shortage of staff and PPE, increased workload and insufficient training were the most prevalent barriers.

Outcomes After Transcatheter Aortic Valve Replacement in Patients with Severe Aortic Stenosis and Diastolic Dysfunction.

OBJECTIVES: Left ventricular diastolic dysfunction (LVDD) in patients undergoing transcatheter aortic valve replacement (TAVR) is associated with poor outcomes; however, the effect of its severity is controversial. We sought to assess the impact of diastolic dysfunction on hospital outcomes and survival after TAVR and identify prognostic factors. METHODS: We included patients who underwent TAVR for severe aortic stenosis with preexisting LVDD from 2009 to 2018 (n = 325). Patients with prior mitral valve surgery (n = 4), atrial fibrillation (n = 39), missing or poor baseline diastolic dysfunction assessment (n = 36) were excluded. The primary endpoint was all-cause mortality. 246 patients were included in the study. RESULTS: The median age was 80 years (25th and 75th percentiles:75-86.7), 154 (62.6%) were males and the median EuroSCORE II was 4.3 (2.2-8). Patients with severe LVDD had significantly higher EuroSCORE, and lower ejection fraction (p < 0.001). There was no difference in post-TAVR new atrial fibrillation (p = 0.912), pacemaker insertion (p = 0.528), stroke (p = 0.76), or hospital mortality (p = 0.95). Patients with severe LVDD had longer hospital stay (p = 0.036). The grade of LVDD did not affect survival (log-rank = 0.145) nor major adverse cardiovascular events (log-rank = 0.97). Predictors of mortality were; low BMI (HR: 0.95 (0.91-0.99); p = 0.019), low sodium (0.93 (0.82-2.5); p = 0.021), previous PCI (HR: 1.6 (1.022-2.66); p = 0.04), E-peak (HR: 1.01 (1.002-1.019); p = 0.014) and implantation of more than one device (HR: 3.55 (1.22-10.31); p = 0.02). CONCLUSION: Transcatheter aortic valve replacement is feasible in patients with diastolic dysfunction, and the degree of diastolic dysfunction did not negatively affect the outcome. Long-term outcomes in those patients were affected by the preoperative clinical state and procedure-related factors.

Delphi consensus on research priorities in tobacco use and substance abuse in Saudi Arabia.

This is the first study to develop research priorities in tobacco use and substance abuse in Saudi Arabia. Health personnel and community volunteers participated in a national internet survey using the Delphi method. In Round 1, 75 experts identified 33 research priorities. In Round 2, 47 experts divided those research priorities into five primary research categories. The panelists then scored both the categories and priorities. Preventive services received the highest priority in research categories. Smoking relapse and its determinants were ranked the top research priorities. Future research should focus on cigarette smoking relapse and factors associated with long-term smoking cessation.