Comparison of sequential and mixture injections of opioids and hyperbaric bupivacaine for subarachnoid block for lower segment caesarean section: a randomised controlled study.

INTRODUCTION: Opioids are commonly added to local anaesthetic for subarachnoid block for caesarean section due to their synergistic effects. The physiochemical characteristics of opioids suggest premixing with hyperbaric bupivacaine may limit their distribution within the CSF. We studied the effect of a separate injection with a combination of bupivacaine, morphine and fentanyl on block characteristics, haemodynamic changes, postoperative pain and patient satisfaction. METHOD: Following ethical approval and informed consent, a prospective double-blinded randomised controlled trial was performed in a university hospital. A total of 126 patients undergoing caesarean section were randomised to two groups. In group M, the premixed group, patients received 12 mg of hyperbaric bupivacaine, 20 mcg of fentanyl and 100 mcg of morphine injected as a single mixture. In group S, the separate injection group, patients received the same drugs in separate injections. Measurements included haemodynamics, block distribution, intra- and postoperative pain, as well as patient satisfaction. RESULTS: Patients in both groups had similar block height, time to maximum sensory block, time to block regression and motor block. However, haemodynamics were different between the groups. The proportion of systolic hypotension episodes was greater in group S [159/1320 (12.05%)] than group M [113/1452 (7.78%)], with P = 0.0002. Moreover, a greater amount of ephedrine was administered in group S than group M, with values 12.09 (8.1) and 9.09 (8.5) mg respectively (P = 0.001). Additionally, postoperative pain, as measured by the Visual Analogue Scale (VAS), was greater in group M, with a VAS of 4.6 (1.7), vs. group S, which recorded a VAS of 3.8 (2.0) (P = 0.017). CONCLUSION: Sequential injection of intrathecal opioids and hyperbaric bupivacaine resulted in greater early haemodynamic instability and slightly better postoperative analgesia without any difference in block height or patient satisfaction. CLINICAL TRIAL REGISTRATION: NCT04403724.

Triple injection peri-sartorius (TIPS) block for postoperative analgesia after total knee arthroplasty: Randomised controlled study.

Background and Aims: Motor-sparing analgesia after total knee arthroplasty (TKA) is crucial. The primary endpoint was the postoperative visual analogue scale (VAS) score after triple injection peri-sartorius (TIPS) block after TKA. Secondary endpoints were postoperative morphine consumption, 24-h postoperative ambulation distances and the degrees of active knee extension. Methods: After general anaesthesia or spinal anaesthesia administration and before surgical incision, 80 patients undergoing TKA were randomised into group TIPS (received ultrasound-guided TIPS block where 40 ml 0.25% bupivacaine and 4 mg dexamethasone were injected: 10 ml at the distal femoral triangle, 10 ml above the sartorius and 20 ml at the distal adductor canal) and group FNB (femoral nerve block; received ultrasound-guided FNB with 20 ml 0.25% bupivacaine mixed with 4 mg dexamethasone). Postoperative pain score was noted and compared. Results: Dynamic VAS scores were lower in the TIPS group than in FNB, while the resting VAS scores were not significantly different. Mean (standard deviation [SD]) postoperative morphine consumption was 5.82 (2.47) mg in the TIPS group (95% confidence interval [CI] 5.03,6.61) versus 9.87 (2.99) mg in the FNB group (95% CI 8.91,10.83). Ambulation distances and active postoperative knee extension in the TIPS group showed greater significance than in the FNB group (TIPS: 18.0 [7.37] m, 95% CI 15.64,20.35] vs. FNB: 8.95 [5.93] m, 95% CI 7.05,10.84) and (TIPS: 52.12 [16.39], 95% CI 46.88,57.33 vs. FNB: 26.05 [11.10], 95% CI 22.501,29.59). Nausea was more evident in FNB patients. Conclusion: TIPS block provides superior analgesia than FNB with motor sparing of the quadriceps after TKA.

Assessment of Posterior Maxillary Alveolar Bone for Immediate Implant Placement: A Quantitative and Qualitative Analysis.

OBJECTIVES: The aims of this study were to evaluate posterior maxillary alveolar bone dimensions and to compare these dimensions in males and females. MATERIALS AND METHODS: The sample consisted of 102 cone beam computed tomography (CBCT) images for 62 male patients (mean age 29.92 ± 9.04 years) and 40 female patients (mean age 29.70 ± 9.54 years). Four distances and three densities were measured; a multivariate analysis of variance and Mann-Whitney's U test were applied to compare the differences between sexes. RESULTS: For the first maxillary molar, there were significant differences between males and females in terms of coronal width (13.95 ± 1.31 and 13.22 ± 1.159 mm, respectively) and middle width (14.28 ± 1.43 and 13.57 ± 1.478 mm, respectively). However, no significant difference was found regarding height (7.93 ± 3.8 mm for both) or apical width (14.68 ± 2 mm for both). Regarding the second maxillary molar, significant differences between males and females were found in terms of coronal width (14.66 ± 1.63 and 13.54 ± 1.512 mm, respectively), middle width (14.35 ± 1.825 and 13.25 ± 1.52 mm, respectively), and height (7.29 ± 3.00 and 8.66 ± 3.16 mm, respectively), whereas the gender dimorphism regarding apical width had borderline significance (14.09 ± 1.731 mm; p = 0.048). No significant differences were found regarding density. CONCLUSION: The minimum average alveolar bone height for the second maxillary molar region was 7.29 ± 30 mm with significant gender dimorphism. Therefore, CBCT scans should be recommended prior to immediate implant placement.

Epidemiology of burns in a humanitarian setting: A national study among refugees in Lebanon.

INTRODUCTION: Burns represent one of the leading causes of morbidity worldwide and disproportionately impact women, children, and socioeconomically disadvantaged individuals. Syrian refugees who fled conflict to land in overcrowded informal settlements across Lebanon are a particularly vulnerable population. This study aims to assess the etiology and risk factors for burns in this population. METHODS: This cross-sectional, cluster-based population study adopted the Surgeons Overseas Assessment of Surgical Need (SOSAS) version 3.0 to capture data from refugees residing in informal settlements in multiple regions across Lebanon. The tool was contextualized and used to collect detailed information on burn cases sustained by refugees during the last 12 months prior to data collection. Univariate logistic regression models were performed to assess the relationship between burns and associated risk factors. RESULTS: From the 1468 households surveyed, a total of 223 households experienced a burn in the last 12 months. Over 63% of burns occurred in children under the age of ten years and almost 57% of burns occurred in females. More than 70% of burns resulted from hot liquid, while 17% were caused by direct heat contact. Over 3/4ths of burns occurred while preparing food (77.4%). Approximately 32% of those burned did not seek healthcare, of which almost 85% noted the cause was mainly due to financial limitations. CONCLUSION: Burns are a common injury in the Syrian refugee population living in Lebanon. Children and women are particularly impacted, often during cooking. Multi-level interventions are necessary to reduce burn injuries and improve care for those affected by burns. Community kitchens can be used to separate cooking and living environments and get stoves and hot liquids off the floor. Importantly, policies should allow for refugees to receive medical care when necessary without a major financial burden.

Hydrothermal extraction and physicochemical characterization of biogenic hydroxyapatite nanoparticles from buffalo waste bones for in vivo xenograft in experimental rats.

Hydroxyapatite (HA) can be used in odontology and orthopedic grafts to restore damaged bone due to its stable chemical characteristics, composition, and crystal structural affinity for human bone. A three-step hydrothermal method was used for the extraction of biogenic calcined HA from the buffalo waste bones at 700 °C (HA-700) and 1000 °C (HA-1000). Extracts were analyzed by thermogravimetric analysis, differential scanning calorimetry, X-ray fluorescence, X-ray diffraction, Fourier transform infrared spectroscopy, scanning electron microscopy, and in vivo examination of HA xenografts for femoral lesions in experimental rats. Crystallinity, purity, and morphology patterns showed that the HA main phase purity was 84.68% for HA-700 and 88.99% for HA-1000. Spherical HA nanoparticles were present for calcined HA-700 samples in the range 57-423 nm. Rats with critical bone lesions of 3 mm in diameter in the left femur treated with calcined HA-700 nanoparticles healed significantly (p < 0.001) faster than rats treated with HA-1000 or negative controls. These findings showed that spherical biogenic HA-700 NPs with a bud-like structure have the potential to stimulate both osteoconduction and bone remodeling, leading to greater bone formation potential in vivo. Thus, the calcined biogenic HA generated from buffalo waste bones may be a practical tool for biomedical applications.

Physical injuries and burns among refugees in Lebanon: implications for programs and policies.

BACKGROUND: Refugees are prone to higher risks of injury due to often austere living conditions, social and economic disadvantages, and limited access to health care services in host countries. This study aims to systematically quantify the prevalence of physical injuries and burns among the refugee community in Western Lebanon and to examine injury characteristics, risk factors, and outcomes. METHODS: We conducted a cluster-based population survey across 21 camps in the Beqaa region of Lebanon from February to April 2019. A modified version of the 'Surgeons Overseas Assessment of Surgical Need (SOSAS)' tool (Version 3.0) was administered to the head of the refugee households and documented all injuries sustained by family members over the last 12 months. Descriptive and univariate regression analyses were performed to understand the association between variables. RESULTS: 750 heads of households were surveyed. 112 (14.9%) households sustained injuries in the past 12 months, 39 of which (34.9%) reported disabling injuries that affected their work and daily living. Injuries primarily occurred inside the tent (29.9%). Burns were sustained by at least one household member in 136 (18.1%) households in total. The majority (63.7%) of burns affected children under 5 years and were mainly due to boiling liquid (50%). Significantly more burns were reported in households where caregivers cannot lock children outside the kitchen while cooking (25.6% vs 14.9%, p-value = 0.001). Similarly, households with unemployed heads had significantly more reported burns (19.7% vs. 13.3%, p value = 0.05). Nearly 16.1% of the injured refugees were unable to seek health care due to the lack of health insurance coverage and financial liability. CONCLUSIONS: Refugees severely suffer from injuries and burns, causing substantial human and economic repercussions on the affected individuals, their families, and the host healthcare system. Resources should be allocated toward designing safe camps as well as implementing educational awareness campaigns specifically focusing on teaching about heating and cooking safety practices.

Single puncture combined lumbar erector spinae plane and quadratus lumborum block (SEQ block) in acetabular fracture surgeries: randomized clinical trial.

BACKGROUND: Acetabular fracture surgery can cause severe postoperative pain. A combined lumbar erector spinae plane block and paraspinous sagittal shift quadratus lumborum block may augment analgesia. METHODS: Fifty two patients undergoing posterior column acetabular surgery were divided into: Group Single puncture combined lumbar Erector spinae and Quadratus lumborum block (SEQ), patients who received SEQ block before anesthesia; and Group morphine (MOR), those who received general anesthesia (GA) and morphine. RESULTS: Demographic characteristics were comparable. The heart rate and mean arterial blood pressure were significantly lower in the SEQ group than in the MOR group between 60 and 180 min intraoperatively (P < 0.001). Postoperative resting and dynamic visual analogue scale scores in the SEQ group were significantly lower than those in the MOR group at all studied periods (P = 0.022-0.001), except at 20 and 24 h postoperatively. Fentanyl was required in all MOR group patients at a mean dose of 110.0 ± 28.42 µg while 18 patients required fentanyl in SEQ group at a mean dose of 60.55 ± 25.54 µg. Postoperative morphine consumption was significantly less in SEQ group (6.33 ± 2.37 mg) than MOR group (17.0 ± 2.55 mg). Postoperative nausea and vomiting were recorded in eight and four patients in MOR and SEQ group, respectively. No complications associated with the block technique were observed. CONCLUSIONS: The SEQ block reduces the postoperative opioid consumption and provides stable intra and postoperative hemodynamics without observed complications in posterior column acetabular surgery.

Post-ablation augmentation of skin sympathetic nerve activity predicts a poor outcome of idiopathic ventricular arrhythmias.

BACKGROUND: The neuromodulation effect after ventricular arrhythmia (VA) ablation is unclear. The study aimed to investigate skin sympathetic nerve activity (SKNA) changes in patients receiving catheter ablations for idiopathic VA. METHODS: Of 43 patients with drug-refractory symptomatic VA receiving ablation, SKNA was continuously recorded for 10 min during resting from electrocardiogram lead I configuration and bipolar electrodes on the right arm 1 day before and 1 day after ablation. RESULTS: Twenty-two patients with acute procedure success and no recurrence during follow-ups were classified as sustained success group (group 1). Other 21 patients were classified as failed ablation group (group 2). Baseline SKNA showed no significant difference between the two groups. Post-ablation SKNA in group 2 was significantly higher than in group 1. In patients with ablation involved right ventricular outflow tract (RVOT), the post-ablation SKNA was also significantly higher in group 2. In contrast, there was no difference in post-ablation SKNA between groups in patients receiving non-RVOT ablation. CONCLUSION: The neuromodulation response after RVOT ablation may correspond to the sympathetic nerve distribution at RVOT. Augmentation of sympathetic activity after VA ablation indicates an unsuccessful VA suppression, especially in patients receiving ablation of RVOT VA.

10-Year Outcomes of Patients With Non-Paroxysmal Atrial Fibrillation Undergoing Catheter Ablation.

BACKGROUND: Radiofrequency catheter ablation (RFCA) is commonly performed in patients with non-paroxysmal atrial fibrillation (AF), but because very long-term follow-up results of RFCA are limited, we investigated the 10-year RFCA outcomes of non-paroxysmal AF.Methods and Results: We retrospectively enrolled 100 patients (89 men, mean age 53.5±8.4years) with drug-refractory symptomatic non-paroxysmal AF who underwent 3D electroanatomic-guided RFCA. Procedural characteristics at index procedures and clinical outcomes were investigated. In the index procedures, all patients had pulmonary vein isolation, 56 (56.0%), 48 (48.0%), and 32 (32.0%) underwent additional linear, complex fractionated atrial electrogram (CFAE) and non-pulmonary vein (NPV) foci ablations, respectively. After 124.1±31.7 months, 16 (16%) patients remained in sinus rhythm after just 1 procedure (3 with antiarrhythmic drugs [AAD]) and after multiple (2.1±1.3) procedures in 53 (53.0%) patients (22 with AAD). Left atrial (LA) diameter (hazard ratio HR 1.061; 95% confidence interval (CI) 1.020 to 1.103; P=0.003), presence of NPV triggers (HR 1.634; 95% CI 1.019 to 2.623; P=0.042) and undergoing CFAE ablation (HR 2.003; 95% CI 1.262 to 3.180; P=0.003) in the index procedure were independent predictors for recurrent atrial tachyarrhythmia. CONCLUSIONS: The 10-year outcomes of single RFCA in non-paroxysmal AF were unsatisfactory. Enlarged LA, presence of NPV triggers, and undergoing CFAE ablation in the index procedure independently predicted single-procedure recurrence. Multiple procedures are required to achieve adequate rhythm control.

Synthesis of Metalorganic Copolymers Containing Various Contorted Units and Iron(II) Clathrochelates with Lateral Butyl Chains: Conspicuous Adsorbents of Lithium Ions and Methylene Blue.

We report the synthesis of three highly soluble metalorganic copolymers, TCP1-3, that were made from a one-pot complexation of iron(II) clathrochelate units that are interconnected by various thioether-containing contorted groups. TCP1-3 were converted into their poly(vinyl sulfone) derivatives OTCP1-3 quantitatively via the selective oxidation of the thioether moieties into their respective sulfones. All of the copolymers, TCP1-3 and OTCP1-3, underwent structural analysis by various techniques; namely, 1H- and 13C-nuclear magnetic resonance (NMR), Fourier transform infrared (FTIR), X-ray photoelectron spectroscopy (XPS), and gel permeation chromatography (GPC). The copolymers were tested as potent lithium ions adsorbents revealing a maximum adsorption (qm) value of 2.31 mg g-1 for OTCP2. Furthermore, this same copolymer was found to be a promising adsorbent of methylene blue (MEB); an isothermal adsorption study divulged that OTCP2's uptake of MEB from an aqueous solution (following the Langmuir model) was, at maximum adsorption capacity, (qm) of 480.77 mg g-1; whereas the kinetic study divulged that the adsorption follows pseudo second-order kinetics with an equilibrium adsorption capacity (qe,cal) of 45.40 mg g-1.

Insufficient Evidence to Ascertain the Long-Term Survival of PEEK Dental Prostheses: A Systematic Review of Clinical Studies.

INTRODUCTION: Polyetheretherketone (PEEK) is a polymer that is used in the construction of orthopaedic and dental implants. It is also used to construct removable and fixed dental prostheses due to its superior mechanical and esthetic properties compared to conventional materials. This systematic review aims to analyse and appraise the literature concerning PEEK dental prostheses critically. METHODS: The following focused question was constructed 'Are dental prostheses made of PEEK inferior to those made of other materials in terms of clinical- and patient-reported outcomes?'. The CONSORT (Consolidated Standards of Reporting Trials) tool was used for the quality assessment of the randomised clinical trials. The STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) quality assessment tool was used to assess the quality of observational studies and the case reports were evaluated using the CARE (Case Report) guidelines. RESULTS: A total of 12 studies were included in this review. Two case studies received an overall grade of medium and the overall quality of six studies was graded as 'low'. All three observational studies and the only randomised controlled trial received scores of 'medium'. CONCLUSION: PEEK-based dental prostheses may provide a viable and more esthetic alternative to conventional prosthodontic appliances. However, within the limitations of this study is the evidence to ascertain the long-term viability of PEEK-based dental prostheses. Future studies should focus on conducting large-scale, multicenter trials to compare the survival rate of PEEK prostheses to that of conventionally available prosthodontic appliances.

Effect of Attachment Type, Maximum Occlusal Force, and Denture Deformation on Marginal Bone Loss of Two-Implant Overdentures: A Short-Term Clinical Trial.

PURPOSE: This study aimed to investigate the effect of attachment type, maximum occlusal force, denture deformation, and other confounding factors on marginal bone loss of two-implant overdentures after 1 year. MATERIALS AND METHODS: Ninety edentulous patients received two implants in canine areas of the mandible using the computer-guided flapless surgical technique. Three months later, overdentures were connected to the implants with bar, resilient telescopic, and resilient stud attachments. Marginal bone loss was evaluated using standardized digitized periapical radiographs. Maximum occlusal forces were evaluated using a digital bite-force meter. Denture base deformation (denture strains, µm) was evaluated using strain gauges bonded to the polished surface of the denture at the level of the attachments. Regression analysis was adopted to find the relation between marginal bone loss and the following confounders (age, sex, mandibular bone height, period of edentulism, number of previous dentures, attachment type, maximum occlusal force, and denture strains). RESULTS AND CONCLUSION: Telescopic overdentures showed the highest marginal bone loss and maximum occlusal force, followed by bar overdentures, and stud overdentures demonstrated the lowest values. The highest denture strains were noted with bar overdentures, followed by telescopic overdentures, and stud overdentures showed the lowest strains. Age (P = .022), mandibular bone height (P = .023), number of previous dentures (P = .004), maximum occlusal force (P ≤ .001), and denture strains (P = .048) were significantly correlated with marginal bone loss. For every 1-year increase in age, there was a decrease in bone loss by 0.3%. For every 1-mm increase in bone height, there was an increase in bone loss by 1%. For every one increase in the number of worn dentures, there was a decrease in bone loss by 4.2%. For every 10-N increase in maximum occlusal force, there was an increase in bone loss by 6.4%. For every 10-µm increase in denture strains, there was an increase in bone loss by 0.21%. Sex, time of edentulism, and attachment type did not demonstrate a significant correlation with marginal bone loss.

Discovery of new pyrimido[5,4-c]quinolines as potential antiproliferative agents with multitarget actions: Rapid synthesis, docking, and ADME studies.

A novel series of pyrimido[5,4-c]quinoline derivatives variously substituted at positions 2 and 5 have been synthesized, in good to excellent yields, via rapid base-catalyzed cyclization reaction of 2,4-dichloroquinoline-3-carbonitrile (5) with guanidine hydrochlorides 6a-c. All the synthesized compounds were screened for their in vitro antiproliferative activity. The most active hybrids 26a-d, 28a-d, and 30B were assessed against topoisomerase (topo) I, topo IIα, CDK2, and EGFR. The majority of the tested compounds exhibited selective topo I inhibitory activity while had weak topo IIα inhibitory action with compounds 30B and 28d, showed better topo I inhibitory activity than the reference camptothecin. Compound 30B, the most potent derivative as antiproliferative agent, exhibited moderate activity against CDK2 (IC50 = 1.60 µM). The results of this assay show that CDK2 is not a potential target for these compounds, implying that the observed cytotoxicity of these compounds is due to a different mechanism. Compounds 30B, 28d, and 28c were found to be the most potent against EGFR and their EGFR inhibitory activities (IC50 = 0.40 ± 0.2, 0.49 ± 0.2, and 0.64 ± 0.3, respectively) relative to the positive control erlotinib (IC50 = 0.07 ± 0.03 µM). These results revealed that topo I and EGFR are attractive targets for this class of chemical compounds.

Exploring Toxins for Hunting SARS-CoV-2 Main Protease Inhibitors: Molecular Docking, Molecular Dynamics, Pharmacokinetic Properties, and Reactome Study.

The main protease (Mpro) is a potential druggable target in SARS-CoV-2 replication. Herein, an in silico study was conducted to mine for Mpro inhibitors from toxin sources. A toxin and toxin-target database (T3DB) was virtually screened for inhibitor activity towards the Mpro enzyme utilizing molecular docking calculations. Promising toxins were subsequently characterized using a combination of molecular dynamics (MD) simulations and molecular mechanics-generalized Born surface area (MM-GBSA) binding energy estimations. According to the MM-GBSA binding energies over 200 ns MD simulations, three toxins-namely philanthotoxin (T3D2489), azaspiracid (T3D2672), and taziprinone (T3D2378)-demonstrated higher binding affinities against SARS-CoV-2 Mpro than the co-crystalized inhibitor XF7 with MM-GBSA binding energies of -58.9, -55.9, -50.1, and -43.7 kcal/mol, respectively. The molecular network analyses showed that philanthotoxin provides a ligand lead using the STRING database, which includes the biochemical top 20 signaling genes CTSB, CTSL, and CTSK. Ultimately, pathway enrichment analysis (PEA) and Reactome mining results revealed that philanthotoxin could prevent severe lung injury in COVID-19 patients through the remodeling of interleukins (IL-4 and IL-13) and the matrix metalloproteinases (MMPs). These findings have identified that philanthotoxin-a venom of the Egyptian solitary wasp-holds promise as a potential Mpro inhibitor and warrants further in vitro/in vivo validation.

The Association Between Initial Serum Bicarbonate Levels and the Management of Dehydrated Children in the Emergency Department: A Retrospective Review.

OBJECTIVES: There is no consensus in the current literature on the relevance of serum bicarbonate levels, cutoff benchmarks and the management of dehydration; therefore, this study aims to explore whether an association can be established between initial serum bicarbonate levels and the subsequent management of children between the ages of 0 to 36 months presenting to the emergency department (ED) with dehydration. METHODS: The study is a single center, retrospective review of 335 charts of children between 0 and 36 months of age presenting to the ED of an urban academic tertiary hospital between June 2014 and June 2016 with a medical history suggestive of dehydration and documented serum bicarbonate levels during their visits. RESULTS: A total of 310 charts were analyzed. No significant difference was found between mean serum bicarbonate levels of admitted and discharged patients (18.82 mmol/L vs 18.75 mmol/L; P = 0.89). Children with serum bicarbonate levels below 15 mmol/L were significantly more likely to receive a fluid bolus ( P = 0.00) in the ED but neither the length of stay in the ED ( P = 0.07) nor in the hospital ( P = 0.41) was affected. Bounce backs within 7 days of discharge were not associated with serum bicarbonate levels at first presentation, but rather with a shorter duration of diarrhea ( P = 0.013). CONCLUSIONS: Initial serum bicarbonate level of dehydrated children does not appear to be associated with the severity of dehydration, vomiting, diarrhea and the patients' management in the ED or the hospital. Initial serum bicarbonate is associated with the decision to administer fluid boluses and potential bounce back.

Road traffic injury in Lebanon: A prospective study to assess injury characteristics and risk factors.

BACKGROUND: Road traffic injury (RTI) is a significant yet poorly characterized cause of morbidity and mortality in the Middle East. This hospital-based-study examined RTI in Lebanon and provided an understanding of their characteristics. METHODS: We collected prospective RTI data from three participating hospitals over 3 months using a designed tool based on Canadian CHIRPP and WHO tools. We performed logistic regression analysis to examine the relationship between contributing risk factors (age, sex) and injury types as well as the association of safety measures used (seatbelts or helmets) and body parts injured. RESULTS: A total of 153 patients were collected. Male preponderance with 72%, with mean age 32.6 (SD = 14.9) years. RTI was highest among passengers aged 15 to 29 (48%). Motorcyclists comprised the greatest injury proportion (38%), followed by vehicle-occupants (35%), and pedestrians (25%) (P = .04). Hip injuries represented the most affected body part (48.7%), followed by head/neck (38.2%). Only 31% (n = 47) of victims applied safety measures (seatbelts or helmets). Six drivers (7%) reported cell phone use at collision. The use of safety measures was associated with a substantial reduction in head/neck injuries (P = .03), spine injuries (P = .049), and lower risk of traumatic brain injury (TBI) (P = .02). CONCLUSIONS: RTI is a major health problem in Lebanon. Safety measures, though poorly adhered to, were associated with less severe injuries, and should be further promoted via awareness campaigns and enforcement. Trauma registries are needed to assess the RTI burden and inform safety interventions and quality-of-care improvement programs.

Surveying and mapping breast cancer services in Ghana: a cross-sectional pilot study in the Eastern Region.

OBJECTIVES: Define the services available for the care of breast cancer at hospitals in the Eastern Region of Ghana, identify areas of the region with limited access to care through geospatial mapping, and test a novel survey instrument in anticipation of a nationwide scale up of the study. DESIGN: A cross-sectional, facility-based survey study. SETTING: This study was conducted at 33 of the 34 hospitals in the Eastern Region of Ghana from March 2020 to May 2020. PARTICIPANTS: The 33 hospitals surveyed represented 97% of all hospitals in the region. This included private, government, quasi-government and faith-based organisation owned hospitals. RESULTS: Sixteen hospitals (82%) surveyed provided basic screening services, 11 (33%) provided pathological diagnosis and 3 (9%) provided those services in addition to basic surgical care.53%, 64% and 78% of the population lived within 10 km, 25 km and 45 km of screening, diagnostic and treatment services respectively. Limited chemotherapy was available at two hospitals (6%), endocrine therapy at one hospital (3%) and radiotherapy was not available. Twenty-nine hospitals (88%) employed a general practitioner and 13 (39%) employed a surgeon. Oncology specialists, pathology personnel and a plastic surgeon were only available in one hospital (3%) in the Eastern Region. CONCLUSIONS: Although 16 hospitals (82%) provided screening, only half the population lived within reasonable distance of these services. Few hospitals offered diagnosis and surgical services, but 64% and 78% of the population lived within a reasonable distance of these hospitals. Geospatial analysis suggested two priorities to cost-effectively expand breast cancer services: (1) increase the number of health facilities providing screening services and (2) centralise basic imaging, pathological and surgical services at targeted hospitals.

Geospatial analysis and impact of targeted development of breast cancer care in The Gambia: a cross-sectional study.

BACKGROUND: The Gambia has one of the lowest survival rates for breast cancer in Africa. Contributing factors are late presentation, delays within the healthcare system, and decreased availability of resources. We aimed to characterize the capacity and geographic location of healthcare facilities in the country and calculate the proportion of the population with access to breast cancer care. METHODS: A facility-based assessment tool was administered to secondary and tertiary healthcare facilities and private medical centers and clinics in The Gambia. GPS coordinates were obtained, and proximity of service availability and population analysis were performed. Distance thresholds of 10, 20, and 45 km were chosen to determine access to screening, pathologic diagnosis, and surgical management. An additional population analysis was performed to observe the potential impact of targeted development of resources for breast cancer care. RESULTS: All 102 secondary and tertiary healthcare facilities and private medical centers and clinics in The Gambia were included. Breast cancer screening is mainly performed through clinical breast examination and is available in 52 facilities. Seven facilities provide pathologic diagnosis and surgical management of breast cancer. The proportion of the Gambian population with access to screening, pathologic diagnosis, and surgical management is 72, 53, and 62%, respectively. A hypothetical targeted expansion of resources would increase the covered population to 95, 62, and 84%. CONCLUSIONS: Almost half of the Gambian population does not have access to pathologic diagnosis and surgical management of breast cancer within the distance threshold utilized in the study. Mapping and population analysis can identify areas for targeted development of resources to increase access to breast cancer care.

Ferric Citrate Dosing in Iron Deficiency Anemia in Nondialysis-Dependent Chronic Kidney Disease.

INTRODUCTION: Ferric citrate (FC) is indicated as an oral iron replacement for iron deficiency anemia in adult patients with chronic kidney disease (CKD) not on dialysis. The recommended starting dose is one 1-g tablet three times daily (TID). This study investigated long-term efficacy and safety of different FC dosing regimens for treating anemia in nondialysis-dependent CKD (NDD-CKD). METHODS: In this phase 4, randomized, open-label, multicenter study, patients with anemia with NDD-CKD (estimated glomerular filtration rate, ≥20 mL/min and <60 mL/min) were randomized 1:1 to one FC tablet (1-g equivalent to 210 mg ferric iron) TID (3 g/day) or 2 tablets twice daily (BID; 4 g/day). At week 12, dosage was increased to 2 tablets TID (6 g/day) or 3 tablets BID (6 g/day) in patients whose hemoglobin (Hb) levels increased <0.5 g/dL or were <10 g/dL. Primary endpoint was mean change in Hb from baseline to week 24. RESULTS: Of 484 patients screened, 206 were randomized and 205 received FC. Mean (standard deviation) changes from baseline in Hb at week 24 were 0.77 (0.84) g/dL with FC TID 3 g/day and 0.70 (0.98) g/dL with FC BID 4 g/day. DISCUSSION/CONCLUSIONS: FC administered BID and TID for 48 weeks was safe and effective for treating anemia in this population, supporting potentially increased dosing flexibility.