Small Bowel Obstruction Secondary to a Metamucil Bezoar: Case Report and Review of the Literature

Bezoar-induced small bowel obstruction is a rare entity. It should be highly suspected in patients with gastric hypomotility disorders, psychiatric conditions, prior abdominal or bariatric surgery, or improper intake of medication. Their diagnosis is quite challenging and surgical exploration remains the best treatment of choice to ensure the viability of the small bowel tissue and relieve the obstruction. This is a case of a 48-year-old female with no previous abdominal surgery who presented with acute abdominal pain. The patient’s history was remarkable for the daily ingestion of 1.5 teaspoons of Metamucil with minimal amount of water. Computed tomography scan demonstrated dilated small bowel loops and a transition zone at the level of the mid jejunum. On laparoscopy, the patient was found to have a hard mass in the mid jejunum amenable to gentle fragmentation and breakdown. Metamucil bezoars are due to the solidification of psyllium-based substances in the gastrointestinal tract. The usual management of small bowel obstruction induced by a bezoar is exploratory laparotomy with enterotomy and primary anastomosis. Laparoscopic intervention has gained popularity among surgeons with good outcome and lower morbidity. In this unusual case, the small bowel obstruction induced by the Metamucil bezoar was safely treated with laparoscopic fragmentation alone

Health care workers in conflict and post-conflict settings: Systematic mapping of the evidence

Background Health care workers (HCWs) are essential for the delivery of health care services in conflict areas and in rebuilding health systems post-conflict. Objective The aim of this study was to systematically identify and map the published evidence on HCWs in conflict and post-conflict settings. Our ultimate aim is to inform researchers and funders on research gap on this subject and support relevant stakeholders by providing them with a comprehensive resource of evidence about HCWs in conflict and post-conflict settings on a global scale. Methods We conducted a systematic mapping of the literature. We included a wide range of study designs, addressing any type of personnel providing health services in either conflict or post-conflict settings. We conducted a descriptive analysis of the general characteristics of the included papers and built two interactive systematic maps organized by country, study design and theme. Results Out of 13,863 identified citations, we included a total of 474 studies: 304 on conflict settings, 149 on post-conflict settings, and 21 on both conflict and post-conflict settings. For conflict settings, the most studied counties were Iraq (15%), Syria (15%), Israel (10%), and the State of Palestine (9%). The most common types of publication were opinion pieces in conflict settings (39%), and primary studies (33%) in post-conflict settings. In addition, most of the first and corresponding authors were affiliated with countries different from the country focus of the paper. Violence against health workers was the most tackled theme of papers reporting on conflict settings, while workforce performance was the most addressed theme by papers reporting on post-conflict settings. The majority of papers in both conflict and post-conflict settings did not report funding sources (81% and 53%) or conflicts of interest of authors (73% and 62%), and around half of primary studies did not report on ethical approvals (45% and 41%). Conclusions This systematic mapping provides a comprehensive database of evidence about HCWs in conflict and post-conflict settings on a global scale that is often needed to inform policies and strategies on effective workforce planning and management and in reducing emigration. It can also be used to identify evidence for policy-relevant questions, knowledge gaps to direct future primary research, and knowledge clusters

Use of Evidence-Based Practice Among Athletic Training Educators, Clinicians, and Students, Part 1: Perceived Importance, Knowledge, and Confidence

Context: Although evidence-based practice (EBP) has become more prevalent, athletic trainers\u27 perceptions of importance and knowledge of these concepts and their confidence in EBP are largely unknown. Objective: To assess perceived importance and knowledge of and confidence in EBP concepts in athletic trainers in various roles and with different degree levels. Design: Cross-sectional study. Setting: Online survey instrument. Patients or Other Participants: The survey was sent to 6702 athletic training educators, clinicians, and postprofessional students. A total of 1209 completed the survey, for a response rate of 18.04%. Main Outcome Measure(s): Demographic information and perceived importance and knowledge of and confidence in the steps of EBP were obtained. One-way analysis of variance, a Kruskal-Wallis test, and an independent-samples t test were used to determine differences in scores among the demographic variables. Results: Athletic trainers demonstrated low knowledge scores (64.2% ± 1.29%) and mild to moderate confidence (2.71 ± 0.55 out of 4.0). They valued EBP as moderately to extremely important (3.49 ± 0.41 out of 4.0). Perceived importance scores differed among roles (clinicians unaffiliated with an education program scored lower than postprofessional educators, P = .001) and highest educational degree attained (athletic trainers with terminal degrees scored higher than those with bachelor\u27s or master\u27s degrees, P \u3c .001). Postprofessional athletic training students demonstrated the highest total EBP knowledge scores (4.65 ± 0.91), whereas clinicians demonstrated the lowest scores (3.62 ± 1.35). Individuals with terminal degrees had higher (P \u3c .001) total knowledge scores (4.31 ± 1.24) than those with bachelor\u27s (3.78 ± 1.2) or master\u27s degrees (3.76 ± 1.35). Postprofessional educators demonstrated greater confidence in knowledge scores (3.36 ± 0.40 out of 4.0) than did those in all other athletic training roles (P \u3c .001). Conclusions: Overall knowledge of the basic EBP steps remained low across the various athletic trainers\u27 roles. The higher level of importance indicated that athletic trainers valued EBP, but this value was not reflected in the knowledge of EBP concepts. Individuals with a terminal degree possessed higher knowledge scores than those with other educational preparations; however, EBP knowledge needs to increase across all demographics of the profession

Leucine-rich α-2 glycoprotein 1 (LRG1) during inflammatory complications after allogeneic stem cell transplantation and CAR-T cell therapy

Background Previous data indicated that the leucine-rich α-2 glycoprotein 1 (LRG1) pathway contributes to vascular dysfunction during cancer growth. Therapeutic targeting of LRG1 normalized tumor vessel dysfunction and enhanced the efficacy of anti-cancer adoptive T cell therapy. A major clinical problem after allogeneic hematopoietic stem cell transplantation (alloHSCT) and after chimeric antigen receptor (CAR) T-cell therapy is the induction of hyperinflammatory side effects, which are typically associated with severe endothelial dysfunction. Methods We investigated LRG1 in preclinical models and in patient samples. Results In prospective studies, we found elevated LRG1 serum levels in patients with cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome after CAR-T-cell therapy as well as in patients with acute graft-versus-host disease (aGVHD) after alloHSCT. In preclinical models of aGVHD, we found vasculature-associated LRG1 upregulation as well as LRG1 pathway gene upregulation. The genetic deletion of LRG1 in alloHSCT donors and in alloHSCT recipients led to reduced clinical and histological aGVHD. In line with this, LRG1 deletion led to clinically and histologically reduced disease severity in experimental inflammatory models of colitis (dextran sulfate sodium colitis) and paw edema. LRG1 deletion reduced inflammation-related vascular leakiness, endothelial cell proliferation, and migration. Conclusions The current data support the hypothesis that LRG1 is an attractive therapeutic target after alloHSCT and after CAR-T cell therapy for cancer because of its role in dysfunctional tumor vessels as well as in inflammatory complications

Illness cognition and health anxiety in parents of children with cancer

Purpose: Health anxiety is a clinical entity characterized by a pathological fear of illness. Illness cognition refers to persistent positive or negative thoughts an individual has towards illness. Evidence has shown that patients with chronic conditions who possess negative illness cognitions experience greater social, emotional, and physical difficulties than patients with positive illness cognitions. This study aims to measure the prevalence of health anxiety in a population of parents of children with cancer, and investigate the association between positive and negative illness cognitions and health anxiety. Methods: We interviewed 105 parents of children with cancer and administered Arabic versions of the Illness Cognition Questionnaire–Parent Version and the Short Health Anxiety Inventory. Results: The mean parental age was 37.7 years with the majority of participants being mothers (78.1%) and married (94.3%) and with 35.2% having completed university education. The average age of the child with cancer was 8.4 years, with the largest proportion of children suffering from leukemia. The prevalence of health anxiety among parents of children with cancer was 21%. The following two dimensions of illness cognition were significantly associated with health anxiety: Helplessness (B = 0.222, p = 0.021) and lower Acceptance (B = −0.242, p = 0.008). Other variables associated with health anxiety were perceived inadequate income (B = −0.238, p = 0.021) and personal illness or illness of a family member/close friend (B = 0.251, p = 0.013). Conclusions: Parents of children with cancer may experience health anxiety. Predictors of health anxiety include feelings of helplessness, lower acceptance, inadequate income, and extended family illnesses. © 2019, © 2019 Taylor & Francis Group, LLC

Lactate/Albumin Ratio as a Predictor of In-Hospital Mortality in Septic Patients Presenting to the Emergency Department

Background: The aim of this study is to evaluate the prognostic value of the Lactate to Albumin (L/A) ratio compared to that of lactate only in predicting morbidity and mortality in sepsis patients. Methods: This was a single-center retrospective cohort study. All adult patients above the age of 18 with a diagnosis of sepsis who presented between January 1, 2014 and June 30, 2019 were included. The primary outcome was in-hospital mortality. Results: A total of 1,381 patients were included, 44% were female. Overall in-hospital mortality was 58.4% with the mortalities of sepsis and septic shock being 45.8 and 67%, respectively. 55.5% of patients were admitted to the intensive care unit. The area under the curve value for lactate was 0.61 (95% CI 0.57–0.65, p < 0.001) and for the L/A ratio was 0.67 (95% CI 0.63–0.70, p < 0.001). The cutoff generated was 1.22 (sensitivity 59%, specificity 62%) for the L/A ratio in all septic patients and 1.47 (sensitivity 60%, specificity 67%) in patients with septic shock. The L/A ratio was a predictor of in-hospital mortality (OR 1.53, CI 1.32–1.78, p < 0.001). Conclusion: The L/A ratio has better prognostic performance than initial serum lactate for in-hospital mortality in adult septic patients. © Copyright © 2020 Bou Chebl, Jamali, Sabra, Safa, Berbari, Shami, Makki, Tamim and Abou Dagher

Hub Angle Control for A Single Link Flexible Manipulator Based on Cuckoo Search Algorithm

Flexible manipulators are one of the promising devices that can be applied in many fields especially in automation and manufacturing fields as they are designed to reduce energy consumption and increase the speed of operation. However, agitation process experienced in the complex structure of the system which causes unwanted vibration will affect the precision of operation. Thus, an efficient control system is required to make them functional. Therefore, the development of an accurate model of flexible manipulator was presented prior to establishing active vibration control to suppress the vibration and increase efficiency of the system. This paper presents the development of a Proportional-IntegralDerivative controller based on cuckoo search algorithm for a single link flexible manipulator system. Initially, the system was modelled using input and output experimental data of the hub angle. System identification was implemented via swarm intelligence algorithm known as cuckoo search algorithms based on auto regressive with exogenous model structure. Then, the performance of proposed algorithms was validated based on three robustness methods known as mean squared error, pole zero diagram stability and correlation tests. The simulation results showed superior performance of cuckoo search algorithm by achieving lowest mean squared error, good correlation tests and high root locus stability. Then, the cuckoo search model was implemented in the proposed control scheme with the aim of accurate positioning at the end point of flexible manipulator

Pediatric emergency department utilisation during Ramadan: A retrospective cross-sectional study

Objective To investigate the impact of Ramadan on patient characteristics, diagnoses and metrics in the paediatric emergency department (PED). Design Retrospective cross-sectional study. Setting PED of a tertiary care centre in Lebanon. Patients All paediatric patients. Exposure Ramadan (June 2016 and 2017) versus the months before and after Ramadan (non-Ramadan). Main outcome measures Patient and illness characteristics and PED metrics including peak patient load; presentation timings; length of stay; and times to order tests, receive samples and report results. Results We included 5711 patients with mean age of 6.1±5.3 years and 55.4% males. The number of daily visits was 28.3±6.5 during Ramadan versus 31.5±7.3 during non-Ramadan (p=0.004). The peak time of visits ranged from 18:00 to 22:00 during non-Ramadan versus from 22:00 to 02:00 during Ramadan. During Ramadan, there were significantly more gastrointestinal (GI) and trauma-related complaints (39.0% vs 35.4%, p=0.01 and 2.9% vs 1.8%, p=0.005). The Ramadan group had faster work efficiency measures such as times to order tests (21.1±21.3 vs 24.3±28.1 min, p<0.0001) and to collect samples (50.7±44.5 vs 54.8±42.6 min, p=0.03). Conclusions Ramadan changes presentation patterns, with fewer daily visits and a later peak time of visits. Ramadan also affects illness presentation patterns with more GI and trauma cases. Fasting times during Ramadan did not affect staff work efficiency. These findings could help EDs structure their staffing to optimise resource allocation during Ramadan. © BMJ Publishing Group Limited 2020

Relative Hyperlactatemia in the Emergency Department

Objective: The clinical interpretation of lactate ≤ 2.00 mmol/L in emergency department (ED) patients is not well-characterized. This study aims to determine the optimal cutoff value for lactate within the reference range that predicts in-hospital mortality among ED patients. Methods: This was a retrospective study of adult patients presenting to a tertiary ED with an initial serum lactate level of <2.00 mmol/L. The primary outcome was in-hospital mortality. Youden's index was utilized to determine the optimal threshold that predicts mortality. Patients above the threshold were labeled as having relative hyperlactatemia. Results: During the study period, 1,638 patients were included. The mean age was 66.9 ± 18.6 years, 47.1% of the population were female, and the most prevalent comorbidity was hypertension (56.7%). The mean lactate level at presentation was 1.5 ± 0.3 mmol/L. In-hospital mortality was 3.8% in the overall population, and 16.2% were admitted to the ICU. A lactate level of 1.33 mmol/L was found to be the optimal cutoff that best discriminates between survivors and non-survivors. Relative hyperlactatemia was an independent predictor of in-hospital mortality (OR 1.78 C1.18–4.03; p = 0.02). Finally, relative hyperlactatemia was associated with increased mortality in patients without hypertension (4.7 vs. 1.1%; p = 0.008), as well as patients without diabetes or COPD. Conclusion: The optimal cutoff of initial serum lactate that discriminates between survivors and non-survivors in the ED is 1.33 mmol/L. Relative hyperlactatemia is associated with increased mortality in emergency department patients, and this interaction seems to be more important in healthy patients. © Copyright © 2020 Bou Chebl, Jamali, Mikati, Al Assaad, Abdel Daem, Kattouf, Safa, Makki, Tamim and Abou Dagher