Factors affecting Saudi medical students' engagement during synchronous and asynchronous eLearning and their impacts on the students' academic achievement: a national survey.

BACKGROUND: Nowadays, especially after the COVID-19 pandemic, electronic learning (eLearning) has become a necessity in education. eLearning can be either synchronous, where classes are conducted in real-time, or asynchronous, where students can access the class material at any time. Student-instructor interaction has become essential to the educational process. In the literature, most studies have focused on the preferred methods of eLearning and the barriers to interaction in eLearning. Thus, this study aimed to investigate the factors that affect students' interactions during eLearning and their impacts on students' academic achievements. METHODS: A national cross-sectional study was conducted among clinical and pre-clinical medical students who were attending universities in five regions of the Kingdom of Saudi Arabia. Data were collected using a bespoke online self-administered questionnaire covering sociodemographic features, eLearning barriers, preferences, and the impact of eLearning on students' performance and understanding. RESULTS: This study involved 1371 medical students, of whom 52.37% were male and 51.13% were in their pre-clinical years of medical college. Of the participants, 59.88% (n = 821) preferred synchronous modalities of eLearning, and 33.33% (n = 457) avoided interaction during synchronous lectures. The main predictors of avoiding interaction during online lectures were being male in the clinical years of medical studies, being in a quiet atmosphere, having difficulties using the eLearning platform, having a poor internet connection, having a visual learning style, being insecure, and the presence of opposite-sex students and facilitators. In addition, 12.25% students (n = 168) reported a lower grade point average (GPA), whereas 11.96% (n = 164) reported an improved GPA after eLearning compared with in-person/onsite learning sessions. The GPA fluctuation was related to gender, personality type, learning style, interaction, and eLearning modality preference. Moreover, the students' understanding was enhanced by recorded lectures (n = 1,093, 79.72%) and supportive multimedia (n = 1,037, 75.64%), and the easy to use platform (n = 1037, 75.64%). CONCLUSION: The synchronous modality of eLearning was the preferred teaching method among the medical students. However, multiple individual, technical, and environmental factors affected their interaction, performance, and understanding during these sessions. Hence, future interventional research is recommended to overcome interaction barriers and enhance student performance and understanding of eLearning.

Psychological Stress and Epigenetic Aging in Older Men: The VA Normative Aging Study.

Psychological stress remains an important risk factor for morbidity and mortality throughout the life course. However, there have been counterintuitive findings reported in previous studies of older persons that examine the relationships of perceived psychological stress with DNA methylation-based markers of aging, which also serve as predictors of morbidity and mortality (epigenetic age/clocks). We aimed to replicate and expand findings from existing work by examining relationships of self-reported stress with nine epigenetic clocks: Hannum, Horvath, Intrinsic, Extrinsic, SkinBloodClock, PhenoAge, GrimAge, DNAm Telomere Length, and Pace of Aging. We analyzed data from 607 male participants (mean age 73.2 years) of the VA Normative Aging Study with one to two study visits from 1999 to 2007 (observations = 956). Stress was assessed via the 14-item Perceived Stress Scale (PSS). Epigenetic age was calculated from DNA methylation measured in leukocytes with the HumanMethylation450 BeadChip. In linear mixed effects models adjusted for demographic/lifestyle/health factors, a standard deviation (sd) increase in PSS was associated with Horvath (ß = -0.35-years, 95%CI: -0.61, -0.09, P=0.008) and Intrinsic (ß = -0.40-years, 95%CI: -0.67, -0.13, P=0.004) epigenetic age deceleration. However, in models limited to participants with the highest levels of stress (≥ 75th-percentile), Horvath (ß = 2.29-years, 95%CI: 0.16, 4.41, P=0.04) and Intrinsic (ß = 2.06-years, 95%CI: -0.17, 4.28, P=0.07) age acceleration associations were observed. Our results reinforce the complexity of psychological stress and epigenetic aging relationships and lay a foundation for future studies that explore longitudinal relationships with other adult stress metrics and factors that can influence stress such as resilience measures.

Policies for Climate-Resilient Health Care Infrastructure-An Environmental Justice Priority.

This Viewpoint discusses how bolstering the climate resilience of hospital infrastructure supports environmental justice goals.

Feasibility of a screening tool for sex trafficking in an adult emergency department.

BACKGROUND: Human trafficking (HT) is a human rights violation and public health issue. People with a history of HT are likely to see a physician during their exploitation. A screening tool was developed and implemented in a busy urban emergency department (ED) to aid in the identification of this population. OBJECTIVE: The objective was to retrospectively assess a HT screening tool implemented in an urban ED and evaluate the feasibility of the tool as a component of standard emergency care. METHODS: This was a retrospective observational study conducted at an urban adult ED after the implementation of an original 11-item HT screening tool. Adult patients 18 years and older were screened based on high-risk chief complaints, "red flag" risk factors, or provider gestalt. All patients with a positive screen were offered the opportunity to speak to a social worker, who then determined the patients' likely trafficking status. Data analysis was performed on this group of patients. RESULTS: A total of 26,974 patients were screened in the ED during 2019. Of these patients, 189 of them had a positive screen. A total of 37 patients were confirmed to have a likely sex trafficking status based on the federal definition. Eight of these patients elected to go to a community partner safe house. Positive responses to eight of the questions were significantly associated with likely sex trafficking status. Through regularized regression analysis, the predictive power of the screen was found to be derived from seven of the questions. CONCLUSION: Through the implementation of this screening tool, providers in a busy urban ED were able to identify patients with an experience of sex trafficking and offer them resources using a trauma-informed approach. This study demonstrates the feasibility of implementation of screening in the ED and identifies seven of the questions used as predictive of likely sex trafficking.

Predicting In-Hospital Mortality in Patients Undergoing Percutaneous Coronary Intervention.

BACKGROUND: Standardization of risk is critical in benchmarking and quality improvement efforts for percutaneous coronary interventions (PCIs). In 2018, the CathPCI Registry was updated to include additional variables to better classify higher-risk patients. OBJECTIVES: This study sought to develop a model for predicting in-hospital mortality risk following PCI incorporating these additional variables. METHODS: Data from 706,263 PCIs performed between July 2018 and June 2019 at 1,608 sites were used to develop and validate a new full and pre-catheterization model to predict in-hospital mortality, and a simplified bedside risk score. The sample was randomly split into a development cohort (70%, n = 495,005) and a validation cohort (30%, n = 211,258). The authors created 1,000 bootstrapped samples of the development cohort and used stepwise selection logistic regression on each sample. The final model included variables that were selected in at least 70% of the bootstrapped samples and those identified a priori due to clinical relevance. RESULTS: In-hospital mortality following PCI varied based on clinical presentation. Procedural urgency, cardiovascular instability, and level of consciousness after cardiac arrest were most predictive of in-hospital mortality. The full model performed well, with excellent discrimination (C-index: 0.943) in the validation cohort and good calibration across different clinical and procedural risk cohorts. The median hospital risk-standardized mortality rate was 1.9% and ranged from 1.1% to 3.3% (interquartile range: 1.7% to 2.1%). CONCLUSIONS: The risk of mortality following PCI can be predicted in contemporary practice by incorporating variables that reflect clinical acuity. This model, which includes data previously not captured, is a valid instrument for risk stratification and for quality improvement efforts.

The evolving relationship between conservative states and access to contraception.

Poor access to contraception can lead to several undesired health outcomes, including high rates of unintended pregnancy, high rates of teen pregnancy, spontaneous preterm delivery, preeclampsia and maternal death. Properly addressing these public health issues often require a coordinated response at the state government level. States with conservative legislatures have traditionally fought attempts to expand access to contraception. However, several of these states are now implementing policies that increase access to their citizens. While the motives for each state differ, the goals are the same: reduce poor health outcomes by increasing access to contraception.

Is Acute Care-Oriented Research Ethical in Resource-Limited Settings?

In this case scenario, a medical student, Jenny, is conducting congenital heart disease research in a resource-limited setting faced with water insecurity. She has concerns about how ethical it is for her to conduct advanced clinical research in a region with more basic health needs. The first commentary argues that advanced clinical research in resource-limited settings follows the ethical principle of beneficence and interactional justice but violates the principle of distributive justice. The second commentary questions whether beneficence is enough, since the Belmont Report states that beneficence is the obligation to simultaneously reduce harm and increase benefit. It calls upon public health physician-scientists to think deeply about how to involve communities in their research-and how to insert themselves into health policy development processes.

The Historical Development of Obstetric Anesthesia and Its Contributions to Perinatology.

Scottish obstetrician James Young Simpson first introduced the use of ether and chloroform anesthesia for labor in 1847, just 1 year after William Morton's first successful public demonstration of ether anesthesia at the Massachusetts General Hospital. The contemporaneous development of surgical anesthesia and obstetrics enabled obstetric anesthesia to address the pain of childbirth. Shortly after its introduction, obstetricians raised concerns regarding placental transport, or the idea that drugs not only crossed the placenta, but exerted detrimental effects on the neonate. The development of regional anesthesia and clinical work in obstetric anesthesia and perinatology addressed issues of the safety of the neonate, enabling obstetric anesthesia to safely and dramatically reduce the pain of childbirth.

Effect of atorvastatin on interleukins and prostaglandin E2 in the kidney of type 1 diabetic rats.

The aim of the study was to evaluate a possible effect of atorvastatin on renal interleukins (ILs) and prostaglandin E2 (PGE2) in type 1 diabetic rats. Thirty-two male rats from a local Wister-derived strain were included in this prospective study and were classified into four groups. Each group consisted of eight animals: Group 1, non-diabetic negative controls; Group 2, diabetic positive controls; Group 3, non-diabetic rats receiving atorvastatin for 4 weeks; and Group 4, diabetic rats receiving atorvastatin for 4 weeks. At the end of the designated period, the animals were sacrificed by cervical dislocation, and the kidneys were excised and homogenized to determine the level of IL-1ß, IL-6, IL-10, and PGE2. The study duration was from June 2015 to May 2016 at Al-Ahlyya Amman University, Amman, Jordan. In the kidneys of rats with streptozotocin-induced diabets, the levels of cytokines IL-1ß, IL-6, IL-10, and PGE2 were significantly elevated above those of the control group. This clearly showed a detrimental effect of diabetes on the kidney. Treatment of diabetic rats with atorvastatin caused a decrease in all evaluated cytokines to levels near control values. Our data suggest that atorvastatin has the potential to protect or attenuate diabetes-induced renal injury. However, the possible protective effect of atorvastatin should be supported by clinical evidence.

The feasibility of Rubidium-82 positron emission tomography stress testing in low-risk chest pain protocol patients.

OBJECTIVE: To evaluate the feasibility of dipyridamole-induced reversible ischemia on myocardial perfusion positron emission tomography (PET) imaging using Rubidium-82 (Rb-82 PET) to predict the presence of acute coronary syndrome (ACS) in emergency department (ED) chest pain patients at low risk who were admitted to an observation unit. METHODS: Retrospective cross-sectional study of electronic medical records after computerized record retrieval. We matched all ED chest pain visits to a database of all scans read by cardiology between January 1, 2004 and January 1, 2006. A PET scan was performed at the ED physician's discretion after a negative observation unit workup, including serial cardiac biomarkers and ECGs. Data were collected on a standardized abstraction instrument. RESULTS: There were 7,691 ED visits for chest pain. Among these patients, 1177 had an Rb-82 PET. Fifty four (4.6%) of these patients had an abnormal or probably abnormal scan. Of these, 28 had catheter-proven significant coronary disease, requiring either revascularization or intensive medical management; 22 patients had ACS by clinical assessment but did not undergo catheterization. Four had no coronary artery disease on catheterization. CONCLUSION: In a low-risk chest pain population, cardiac PET imaging had true-positive cardiac catheterization rates which were comparable to prior studies of SPECT sestimibi imaging and coronary CTA imaging. With the rapid dissemination of PET technology, and superior performance compared to current imaging methods, myocardial perfusion PET is a feasible alternative to traditional provocative testing in an ED observation unit.

The last days of dying stroke patients referred to a palliative care consult team in an acute hospital.

BACKGROUND AND PURPOSE: Needs of patients dying from stroke are poorly investigated. We aim to assess symptoms of these patients referred to a palliative care consult team, and to review their treatment strategies. METHODS: All charts of patients dying from stroke in a tertiary hospital, and referred consecutively to a palliative care consultant team from 2000 to 2005, were reviewed retrospectively. Symptoms, ability to communicate, treatments, circumstances and causes of death were collected. RESULTS: Forty-two patients were identified. Median NIH Stroke Scale on admission was 21. The most prevalent symptoms were dyspnoea (81%), and pain (69%). Difficulties or inability to communicate because of aphasia or altered level of consciousness were present in 93% of patients. Pharmacological respiratory treatments consisted of anti-muscarinic drugs (52%), and opioids (33%). Pain was mainly treated by opioids (69%). During the last 48 h of life, 81% of patients were free of pain and 48% of respiratory distress. The main causes of death were neurological complications in 38% of patients, multiple medical complications in 36%, and specific medical causes in 26%. CONCLUSIONS: Patients dying from stroke and referred to a palliative care consult team have multiple symptoms, mainly dyspnoea and pain. Studies are warranted to develop specific symptoms assessment tools in non-verbal stroke patients, to accurately assess patients' needs, and to measure effectiveness of palliative treatments.

Assessment of iodine-treated filter media for removal and inactivation of MS2 bacteriophage aerosols.

AIMS: To investigate the performance of an iodine-releasing filter medium for use as a protective device against airborne pathogens. METHODS AND RESULTS: The filter's physical and viable removal efficiencies (VRE) were investigated with challenges of MS2 bacteriophage aerosols, and the infectivity of MS2 collected on the filter was analysed. To test a proposed inactivation mechanism, media containing thiosulfate or bovine serum albumin (BSA) were put in impingers to quench and consume I(2) released from the filter. In direct plating experiments, treated filters presented significantly higher VREs than did untreated filters; however, collection in excess BSA decreased VRE by half and in thiosulfate the apparent VRE decreased drastically. No significant difference in infectivity of retained viruses on treated and untreated filters was observed at the same environmental condition. CONCLUSIONS: Evidence presented herein for competition by dissolved I(2) in infectivity assays supports a mechanism of induced displacement and capture of I(2.) It also requires that dissociation of iodine from the filter and capture of iodine by MS2 aerosols as they pass through the filter be factored in the design of the assessment methodology. The filter's strong retention capability minimizes reaerosolization but also makes it difficult to discriminate the antimicrobial effect at the surface. SIGNIFICANCE AND IMPACT OF THE STUDY: This study shows the direct plating assay method to be sensitive to interference by iodine-releasing materials. This requires reevaluation of earlier reports of VRE measurements.

[Painful wounds: a daily challenge, not a fatality]. / Plaies douloureuses: un défi quotidien, non une fatalité.

Long neglected, the pain related to wounds is nowadays recognized as an important issue. This article reviews the physiopathological mechanisms and the types of pain related to wounds, their assessment modalities as well as the pharmacological and non-pharmacological analgesic treatments.

Intracellular localization of glutamine synthetase in a nitrogen-fixing cyanobacterium Anabaena cylindrical.

The major route of ammonia assimilation is the reaction which is catalyzed by glutamine synthetase to give ammonia. Cell-free extracts and purified thylakoid membranes using differential centrifugation and density gradient techniques were assayed for the percentage activity of the enzyme. Glutamine synthetase was detected in all cell-free extracts. Seventy six percent of the enzyme activity was found associated with the thylakoid membranes. Using antiserum raised to the thylakoids, 78.5% inhibition of the enzyme activity was obtained.

Causes of macrocytosis in HIV-infected patients not treated with zidovudine. Swiss HIV Cohort Study.

OBJECTIVE: Zidovudine is a well known cause of macrocytosis. However, many HIV-infected patients develop macrocytosis even though they do not receive zidovudine. The aim of this case-control study was to evaluate other causes of high mean corpuscular volumes (MCV) in HIV infected patients. METHODS: Thirty patients with a MCV > or = 100 fl (cases) were compared to 60 randomly selected controls with MCV A< or = 99 fl, none of them receiving zidovudine. RESULTS: Sex ratio, age, mean CD4, prevalence of alcohol abuse and liver disease were similar in both groups. Vitamin B12 or folic acid levels were not decreased in patients with macrocytosis. In contrast, there was an association between macrocytosis and use of stavudine alone or in combination with another antiviral drug (28/30 cases, 15/60 controls, odds ratio 40.6 (95% confidence interval 5.1-325.2), P< 0.001). The haemoglobin concentration among cases (mean 13.5 g/dl) was similar to that of controls (mean 13.0 g/dl). CONCLUSIONS: Stavudine use increase the risk of macrocytosis more than 40-fold in HIV-infected patients who do not receive zidovudine. None of the stavudine-treated patients, however, developed anaemia or had to interrupt treatment because of this side effect.

Impact of treatment with human immunodeficiency virus (HIV) protease inhibitors on hepatitis C viremia in patients coinfected with HIV.

The impact of human immunodeficiency virus (HIV) protease inhibitors on hepatitis C (HCV) viremia was assessed in 19 patients infected with both HIV and HCV. HIV and HCV RNA levels were measured before and during treatment with protease inhibitors. Before treatment, mean levels of HCV RNA were 5.3 log for HCV RNA and 5.0 log for HIV RNA. CD4 lymphocyte counts were 63/mm3. After 6 weeks of treatment, a mean reduction of 2.1 log10 in HIV RNA (P < .001) and a mean (+/-SE) increase of 73 (+/-21) CD4 and 296 (+/-70) CD8 cells were observed (P < .05). In contrast, both HCV viremia (+0.4 log +/- 0.1) and alanine aminotransferase increased (P < .04). HCV RNA levels returned to baseline after 17 and 32 weeks of treatment. Thus, potent anti-HIV regimens with protease inhibitors may temporarily worsen HCV status despite improvement of HIV parameters.

Sinus histiocytosis with massive lymphadenopathy (Rosai Dorfman disease) in an HIV-positive patient.

We report a case of a 31-year-old HIV infected black female, who presented with asymptomatic generalized lymphadenopathy. Three particularly enlarged lymph nodes were biopsied (2 cervical and 1 axillary). The histological picture was consistent with a diagnosis of sinus histiocytosis with massive lymphadenopathy (SHML) or Rosai-Dorfman disease. Large histiocytes, positive for a variety of macrophage markers and for the S-100 protein, were observed in the distended sinuses. A few hyperplastic follicles, such as usually seen in HIV-infection-associated lymphadenopathy, were present at the periphery of one lymph node. No infections agent besides HIV could be detected by histological or microbiological analysis or by in situ hybridization. This is the first reported case of SHML associated with HIV infection. The possible relationship between the two diseases is discussed.