Educational Paradigms in Islamic Medical History: A Review.

The rise of Islam in Arabia witnessed a scientific pursuit from 8th CE to 14th CE in its vast dominion. Medicine was one among many disciplines that was reshaped during the golden ages of Islamic world. Physicians and scholars from diverse faiths and background flocked in learning centers of Baghdad, Cordoba, and other cities. A multicultural environment of medical research was evolved with fundings from state. From medical teaching and clinical training to the licensing of physicians, many of the modern attributes of medical education were pioneered in Islamic world. The scholarly transfusion from European territories of Islamic world to the Western world in medieval era laid the foundation of modern medical education.

Knowledge About Alzheimer's Disease in Saudi Arabia.

Background Alzheimer's disease (AD) is the most common neurodegenerative dementia which constitutes a major healthcare problem globally. This study aimed to assess the pattern and determinants of knowledge about AD in Saudi Arabia. Methodology In this cross-sectional study, information was collected from 286 participants using a validated questionnaire on seven subdomains of knowledge about AD. SPSS (IBM Corp., Armonk, NY, USA) was used for data analysis. Different tests of significance such as the chi-square test and principal component factor analyses were employed. The level of significance was set at 0.05. Results The 25 questions on knowledge, attitudes, and practice about AD had a high Cronbach's alpha (0.911). All scores on the seven subdomains of knowledge, attitudes, and practice about AD were significantly correlated with each other (p < 0.05). The knowledge of the population about AD was very low, with the majority of the correct responses for questions on the different subdomains of knowledge about AD ranging from 10% to 67% (76% of the answers were below 50% correct answers). Females and smokers had higher scores on most subdomains compared to males and non-smokers (p < 0.05). Conclusions Knowledge of the population about AD is very low. As the subdomains of knowledge on AD are correlated, healthcare professionals should implement health education programs on AD to increase the knowledge of the population regarding the course, symptoms, risk factors, treatment and management, and caregiving and reveal their association with the impact of AD on the health of affected individuals.

Patient-reported distress as an early warning sign of unmet palliative care needs and increased healthcare utilization in patients with advanced cancer.

INTRODUCTION: Cancer patients' sources of distress are often unaddressed, and patient-reported distress data could be utilized to identify those with unmet and impending care needs. We explored the association between moderate/severe distress and healthcare utilization in a large sample of non-small cell lung cancer (NSCLC) and non-colorectal gastrointestinal cancer patients. METHODS AND MATERIALS: Adult patients treated between July 2013 and March 2019. Data from the NCCN Distress Thermometer (DT) and the accompanying "Problem List" were extracted from the EHR. A DT score of ≥ 4 indicates "actionable distress." Statistical analysis was performed using descriptive analysis for patient characteristics, clinical outcomes, and sources of distress. Generalized linear mixed models were fit to determine the relationship between distress and healthcare utilization (hospitalization, emergency department (ED) visit, or both). RESULTS: The ten most frequently reported problems were from the Physical and Emotional domains of the Problem List. Distress was mostly related to physical symptoms (pain, fatigue) and emotional issues (worry, fears, sadness, nervousness). Patients with actionable distress generally reported more problems across all their visits. Actionable distress was associated with higher odds of the composite outcome measure of hospitalization or visiting the ED, within both the next 3 months (OR = 1.37; 95% CI = 1.19, 1.58; p < 0.001) and 6 months (OR = 1.19; 95% CI = 1.03, 1.37; p = 0.019). CONCLUSION: Patients with significant distress had marked utilization of ED and inpatient services. DT scores are a source of untapped data in the EHR that can highlight patients in need of intervention, including palliative care and cancer support services.

Postoperative arginine-enriched immune modulating nutrition: Long-term survival results from a randomised clinical trial in patients with oesophagogastric and pancreaticobiliary cancer.

BACKGROUND & AIMS: Immune modulating nutrition (IMN) has been shown to reduce postoperative infectious complications and length of stay in patients with gastrointestinal cancer. Two studies of IMN in patients undergoing surgery for head and neck cancer also suggested that this treatment might improve long-term survival and progression-free survival. In the present study, we analysed follow-up data from our previous randomised controlled trial of IMN, in patients undergoing surgery for oesophagogastric and pancreaticobiliary cancer, in order to evaluate the long-term impact on survival of postoperative IMN versus an isocaloric, isonitrogenous control feed. METHODS: This study included patients undergoing surgery for cancers of the pancreas, oesophagus and stomach, who had been randomised in a double-blind manner to receive postoperative jejunostomy feeding with IMN (Stresson, Nutricia Ltd.) or an isonitrogenous, isocaloric feed (Nutrison High Protein, Nutricia) for 10-15 days. The primary outcome was long-term overall survival. RESULTS: There was complete follow-up for all 108 patients, with 54 patients randomised to each group. There were no statistically significant differences between groups by demographics [(age, p = 0.63), sex (p = 0.49) or site of cancer (p = 0.25)]. 30-day mortality was 11.1% in both groups. Mortality in the intervention group was 13%, 31.5%, 70.4%, 85.2%, 88.9%, and 96.3% at 90 days, and 1, 5, 10, 15 and 20 years respectively. Corresponding mortality in the control group was 14.8%, 35.2%, 68.6%, 79.6%, 85.2% and 98.1% (p > 0.05 for all comparisons). CONCLUSION: Early postoperative feeding with arginine-enriched IMN had no impact on long-term survival in patients undergoing surgery for oesophagogastric and pancreaticobiliary cancer.

Diagnostic Performance of Artificial Intelligence-Based Models for the Detection of Early Esophageal Cancers in Barret's Esophagus: A Meta-Analysis of Patient-Based Studies.

Introduction Barret's esophagus (BE) is a precursor of adenocarcinoma of the esophagus. The detection of high-grade dysplasia and adenocarcinoma at an early stage can improve survival but is very challenging. Artificial intelligence (AI)-based models have been claimed to improve diagnostic accuracy. The aim of the current study was to carry out a meta-analysis of papers reporting the results of artificial intelligence-based models used in real-time white light endoscopy of patients with BE to detect early esophageal adenocarcinoma (EEAC). Methods This meta-analysis was registered with the International Prospective Register of Systematic Reviews (PROSPERO; Reg No. CRD42021246148) and its conduction and reporting followed the Preferred Reporting Items for Systematic Review and Meta-Analysis of Diagnostic Test Accuracy (PRISMA-DTA) statement guidelines. All peer-reviewed and preprint original articles that reported the sensitivity and specificity of AI-based models on white light endoscopic imaging as an index test against the standard criterion of histologically proven early oesophageal cancer on the background of Barret's esophagus reported as per-patient analysis were considered for inclusion. There was no restriction on type and year of publication, however, articles published in the English language were searched. The search engines used included Medline, PubMed, EMBASE, EMCARE, AMED, BNI, and HMIC. The search strategy included the following keywords for all search engines: ("Esophageal Cancer" OR "Esophageal Neoplasms" OR " Oesophageal Cancer" OR "Oesophageal Neoplasms" OR "Barrett's Esophagus" OR "Barrett's Oesophagus") And ("Artificial Intelligence" OR "Deep Learning" OR "Machine Learning" OR "Convolutional Network"). This search was conducted on November 30, 2020. Duplicate studies were excluded. Studies that reported more than one dataset per patient for the diagnostic accuracy of the AI-based model were included twice. Quantitative and qualitative data, including first author, year of publication, true positives (TP), false negatives (FN), false positives (FP), true negatives (TN), the threshold of the index test, and country where the study was conducted, were extracted using a data extraction sheet. The Quality Appraisal for Diverse Studies 2 (QUADS-2) tool was used to assess the quality of each study. Data were analyzed using MetaDTA, interactive online software for meta-analysis of diagnostic studies. The diagnostic performance of the meta-analysis was assessed by a summary receiver operating characteristics (sROC) plot. A meta-analysis tree was constructed using MetaDTA software to determine the effect of cumulative sensitivity and specificity on surveillance of patients with BE in terms of miss rate and overdiagnosis. Results The literature search revealed 171 relevant records. After removing duplicates, 117 records were screened. Full-text articles of 28 studies were assessed for eligibility. Only three studies reporting four datasets met the inclusion criteria. The summary sensitivity and specificity of AI-based models were 0.90 (95% CI, 0.83- 0.944) and 0.86 (95% CI, 0.781-0.91), respectively. The area under the curve for all the available evidence was 0.88. Conclusion Collective evidence for the routine usage of AI-based models in the detection of EEAC is encouraging but is limited by the low number of studies. Further prospective studies reporting the patient-based diagnostic accuracy of such models are required.

Management of atrial fibrillation after transcatheter aortic valve replacement: Challenges and therapeutic considerations.

Atrial Fibrillation (AF) is very common among patients with severe aortic stenosis. Moreover, new onset AF (NOAF) is a frequent finding after Transcatheter Aortic Valve Replacement (TAVR). There is a significant impact of AF on outcomes in patients undergoing TAVR including mortality, thrombo-embolic and bleeding events. There is lack of clear evidence about the optimal management of AF in TAVR patients. This review aims to summarize the epidemiology, predictors, prognosis, therapeutic considerations and challenges in the management of AF in patients undergoing TAVR.

Clinical Significance of Early Hospital Readmission in Continuous-Flow Left Ventricular Assist Device Patients.

Data on the clinical significance of early hospital readmission within 90 days following left ventricular assist device (LVAD) implantation in patients with continuous-flow LVAD are limited. We aimed to assess the incidence, predictors, and outcomes of 90-day readmission in LVAD patients. Hospital readmission or death was assessed within 90 days after hospital discharge in 177 patients with HeartMate II LVADs implanted between May 2008 and June 2014. Predictors of early readmission and risk of death were evaluated using multivariable Cox models following adjustment for clinical covariates. Hospital readmission or death rate was 37% within 90 days. Age at implantation (hazard ratio [HR] = 1.03 per 1 year increase, p = 0.016), diabetes (HR = 2.19, p = 0.031) and smoking at baseline (HR = 2.06, p = 0.034) predicted early hospital readmission, while a higher baseline body mass index was found to be protective (HR = 0.92 per each unit increase in body mass index, p = 0.003). One-year all-cause mortality was 19% in patients with early hospital readmission as compared to 1% with no early hospital readmission (HR 15.50, p = 0.01). One-year mortality was 35% in patients with 2 or more readmissions compared to 10% mortality in patients with one readmission and 1% mortality in patients with no readmissions (p < 0.001). In LVAD patients, there is a high incidence of hospital readmission within 90 days, which is associated with an increased mortality. Targeted interventions, such as closer follow-up to prevent early and recurrent hospital readmissions in LVAD recipients, are warranted to improve outcomes.

A nurse-led implantable loop recorder service is safe and cost effective.

INTRODUCTION: Implantable loop recorders (ILR) are predominantly implanted by cardiologists in the catheter laboratory. We developed a nurse-delivered service for the implantation of LINQ (Medtronic; Minnesota) ILRs in the outpatient setting. This study compared the safety and cost-effectiveness of the introduction of this nurse-delivered ILR service with contemporaneous physician-led procedures. METHODS: Consecutive patients undergoing an ILR at our institution between 1st July 2016 and 4th June 2018 were included. Data were prospectively entered into a computerized database, which was retrospectively analyzed. RESULTS: A total of 475 patients underwent ILR implantation, 271 (57%) of these were implanted by physicians in the catheter laboratory and 204 (43%) by nurses in the outpatient setting. Six complications occurred in physician-implants and two in nurse-implants (P = .3). Procedural time for physician-implants (13.4 ± 8.0 minutes) and nurse-implants (14.2 ± 10.1 minutes) were comparable (P = .98). The procedural cost was estimated as £576.02 for physician-implants against £279.95 with nurse-implants, equating to a 57.3% cost reduction. In our center, the total cost of ILR implantation in the catheter laboratory by physicians was £10 513.13 p.a. vs £6661.55 p.a. with a nurse-delivered model. When overheads for running, cleaning, and maintaining were accounted for, we estimated a saving of £68 685.75 was performed by moving to a nurse-delivered model for ILR implants. Over 133 catheter laboratory and implanting physician hours were saved and utilized for other more complex procedures. CONCLUSION: ILR implantation in the outpatient setting by suitably trained nurses is safe and leads to significant financial savings.

Left Ventricular Reverse Remodeling in Cardiac Resynchronization Therapy and Long-Term Outcomes.

OBJECTIVES: The aim of this study was to evaluate the association between improvement in left ventricular end-systolic volume (LVESV) with cardiac resynchronization therapy (CRT) and mortality and whether this relationship was modified by the presence of a left bundle branch block (LBBB) electrocardiographic pattern. BACKGROUND: Left ventricular reverse remodeling in patients receiving CRT has been shown to predict outcomes. However, the extent to which reverse remodeling contributes to long-term survival is not well understood. METHODS: Changes in LVESV were assessed in MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy) patients receiving CRT with a defibrillator (CRT-D) and echocardiograms available at 1 year (n = 752), stratified by LBBB, relative to long-term all-cause mortality, compared with those with implantable cardioverter-defibrillators (ICDs) only (n = 684). RESULTS: In patients with LBBB, a reduction in LVESV of >35% (median) translated into significantly lower risk for long-term mortality (hazard ratio [HR]: 0.34; p < 0.001), heart failure (HF) events (HR: 0.21; p < 0.001), and HF or death (HR: 0.27; p < 0.001) compared with patients with ICDs only. Patients with reductions in LVESV ≤35% had a significantly lower risk for HF, and HF or death, and a nonsignificantly lower rate of death compared with those with ICDs only (HR: 0.74; p = 0.13). Risk reduction in HF events was uniform across all LVESV quartiles. In patients without LBBB, there was no survival benefit (HR: 0.68; p = 0.271) despite an LVESV reduction greater than the median (>27.6%). CRT-D patients without LBBB with the least reverse remodeling (quartile 1) had a more than 3-fold increased risk for death compared with those with ICDs only (HR: 3.11; p < 0.001). CONCLUSIONS: In patients with LBBB, CRT-D-induced reduction in LVESV at 1 year is associated with long-term survival benefit. Despite left ventricular reverse remodeling with CRT-D, there is no survival benefit and potential harm in patients without LBBB.

Prolonged action potential duration and dynamic transmural action potential duration heterogeneity underlie vulnerability to ventricular tachycardia in patients undergoing ventricular tachycardia ablation.

AIMS: Differences of action potential duration (APD) in regions of myocardial scar and their borderzones are poorly defined in the intact human heart. Heterogeneities in APD may play an important role in the generation of ventricular tachycardia (VT) by creating regions of functional block. We aimed to investigate the transmural and planar differences of APD in patients admitted for VT ablation. METHODS AND RESULTS: Six patients (median age 53 years, five male); (median ejection fraction 35%), were studied. Endocardial (Endo) and epicardial (Epi) 3D electroanatomic mapping was performed. A bipolar voltage of <0.5 mV was defined as dense scar, 0.5-1.5 mV as scar borderzone, and >1.5 mV as normal. Decapolar catheters were positioned transmurally across the scar borderzone to assess differences of APD and repolarization time (RT) during restitution pacing from Endo and Epi. Epi APD was 173 ms in normal tissue vs. 187 ms at scar borderzone and 210 ms in dense scar (P < 0.001). Endocardial APD was 210 ms in normal tissue vs. 222 ms in the scar borderzone and 238 ms in dense scar (P < 0.01). This resulted in significant transmural RT dispersion (ΔRT 22 ms across dense transmural scar vs. 5 ms in normal transmural tissue, P < 0.001), dependent on the scar characteristics in the Endo and Epi, and the pacing site. CONCLUSION: Areas of myocardial scar have prolonged APD compared with normal tissue. Heterogeneity of regional transmural and planar APD result in localized dispersion of repolarization, which may play an important role in initiating VT.

Allogeneic stem cell transplantation from unrelated donors in acute leukaemia.

PURPOSE OF REVIEW: To summarize the past and current knowledge of the use of unrelated donors (URDs) in allogeneic stem cell transplantation for patients with acute leukaemia. RECENT FINDINGS: The outcome of URD stem cell transplants in terms of treatment-related mortality, relapse rates, disease free survival and overall survival is comparable to sibling donors. SUMMARY: Haematopoietic stem cell transplantation (HSCT) is the therapy of choice in many haematological malignant diseases but only one-third of the patients will have an HLA-matched sibling. The possibility of finding a matched URD is more than 70% because of recent advances in HLA typing and continuous expansion of URD registries around the world. The use of URD as a source of stem cells in adult patients are steadily increasing and in the last 8 years, superseded the matched sibling donors and became the most commonly used stem cell source. There is also an increasing trend of using peripheral blood stem cells than bone marrow stem cells. Outcomes following URD transplants depend mainly upon the indication and urgency of transplant, age and comorbidities of recipients, cytomegalovirus matching/mismatching between donor and the recipient and degree of HLA matching.

Perioperative Complications in Patients With Sleep Apnea Undergoing Total Joint Arthroplasty.

BACKGROUND: This study aims to evaluate the effect of sleep apnea (SA) on perioperative complications after total joint arthroplasty (TJA) and whether the type of anesthesia influences these complications. METHODS: Using the ninth and tenth revisions of the International Classification of Diseases, coding systems, we queried our institutional TJA database from January 2005 to June 2016 to identify patients with SA who underwent TJA. These patients were matched in a 1:3 ratio based on age, gender, type of surgery, and comorbidities to patients who underwent TJA but were not coded for SA. Perioperative complications were identified using the same coding systems. Multivariate analysis was used to test if SA is an independent predictor of perioperative complications and if type of anesthesia can affect these complications. RESULTS: A total of 1246 patients with SA were matched to 3738 patients without SA. Pulmonary complications occurred more frequently in patients with SA (1.7% vs 0.6%; P < .001), confirmed using multivariate analysis (odds ratio = 2.91; 95% confidence interval, 1.58-5.36; P = .001). Use of general anesthesia increased risk of all but central nervous system complications and mortality (odds ratio = 15.88; 95% confidence interval, 3.93-64.07; P < .001) regardless of SA status compared with regional anesthesia. Rates of pulmonary and gastrointestinal complications, acute anemia, and mortality were lower in SA patients when regional anesthesia was used (P < .05). CONCLUSION: SA increases risk of postoperative pulmonary complications. The use of regional anesthesia may reduce risk of pulmonary complications and mortality in SA patients undergoing TJA.

Matched unrelated donor transplants-State of the art in the 21st century.

Hematopoietic stem cell transplantation (HSCT) is the therapy of choice in many hematological malignant and non-malignant diseases by using human leukocyte antigen (HLA)-matched siblings as stem cell source but only one third of the patients will have HLA-matched siblings. Hence, physicians rely on the availability of matched unrelated donors (URD). The possibility of finding a matched URD is now more than 70% due to continuous expansion of URD registries around the world. The use of URD in adult patients is steadily increasing and in the last 8 years has superseded the numbers of matched sibling donor transplants and has become the most commonly used stem cell source. There is also an increasing trend to use peripheral blood (PB) stem cells rather than bone marrow (BM) stem cells. Outcomes following URD transplants depend mainly upon the indication and urgency of transplant, age and comorbidities of recipients, cytomegalovirus (CMV) matching/mismatching between donor and the recipient, and degree of HLA matching. In some studies outcome of unrelated stem cell transplants in terms of treatment-related mortality (TRM), disease-free survival (DFS), and overall survival (OS) is comparable to sibling donors.

The evolving landscape of oral anti-arrhythmic prescriptions for atrial fibrillation in England: 1998-2014.

AIMS: An important decision in the management of patients with atrial fibrillation is whether to adopt a rate or rhythm control strategy. Options for the latter include oral membrane-active anti-arrhythmic drugs (AADs) or catheter ablation. Recent prescription trends may have been affected by the introduction of dronedarone and an increasing number of reports suggesting increased mortality in those taking AADs. We describe the trend in oral AAD prescriptions in England in the period 1998-2014. METHODS AND RESULTS: We conducted a retrospective study using data from the Prescription Cost Analysis system, which holds information on every prescription dispensed in the community in England. We obtained data from 1998 to October 2014 for all Class Ia, Ic, and III AADs. Amiodarone and sotalol remain the most commonly prescribed AADs in England, though the use of both is decreasing. There has been a linear increase in the uptake of flecainide. Dronedarone prescriptions peaked in 2011, and our most recent data show that amiodarone prescriptions are 25-fold those of dronedarone. CONCLUSION: There is a decline in the use of amiodarone and sotalol consistent with the growing safety concerns with these drugs along with neutral results from landmark trials comparing rate and rhythm control. Dronedarone has failed to make an impact on AAD prescribing. In contrast, flecainide has seen an increase in use during the study period.

Is CRT pro-arrhythmic? A comparative analysis of the occurrence of ventricular arrhythmias between patients implanted with CRTs and ICDs.

UNLABELLED: Aim and Hypothesis: Despite the proven symptomatic and mortality benefit of cardiac resynchronization therapy (CRT), there is anecdotal evidence it may be pro-arrhythmic in some patients. We aimed to identify if there were significant differences in the incidence of ventricular arrhythmias (VAs) in patients undergoing CRT-D and implantable cardioverter-defibrillators (ICD) implantation for primary prevention indication. We hypothesized that CRT is unlikely to be pro-arrhythmic based on the positive mortality and morbidity data from large randomized trials. METHODS AND RESULTS: A retrospective analysis of device therapies for VA in a primary prevention device cohort was performed. Patients with ischemic (IHD) and non-ischemic (DCM) cardiomyopathy and ICD or CRT+ICD devices (CRT-D) implanted between 2005 and 2007 without prior history of sustained VA were included for analysis. VA episodes were identified from stored electrograms and defined as sustained (VT/VF) if therapy [anti-tachycardia pacing (ATP) or shocks] was delivered or non-sustained (NSVT) if not. Of a total of 180 patients, 117 (68% male) were in the CRT-D group, 42% IHD, ejection fraction (EF) 24.5 ± 8.2% and mean follow-up 23.9 ± 9.8 months. 63 patients (84% male) were in the ICD group, 60% IHD, EF 27.7 ± 7.2% and mean follow-up 24.6 ± 10.8 months. Overall, there was no significant difference in the incidence of VA (35.0 vs. 38.1%, p = 0.74), sustained VT (21.3 vs. 28.5%, p = 0.36) or NSVT (12.8 vs. 9.5%, p = 0.63) and no significant difference in type of therapy received for VT/VF: ATP (68 vs. 66.6%, p = 0.73) and shocks (32 vs. 33.3%, p = 0.71) between the CRT-D and ICD groups, respectively. CONCLUSION: In patients with cardiomyopathy receiving CRT-D and ICDs for primary prophylaxis, there was no significant difference in the incidence of VA. From this single center retrospective analysis, there is no evidence to support cardiac resynchronization causing pro-arrhythmia.