Moral distress is a serious problem in healthcare environments that requires urgent attention and management. It occurs when healthcare providers are unable to provide the care that they feel is ...right or take, what they believe to be, ethically appropriate actions for their patients. Thus, this study aims to examine moral distress among nurses and physicians working in tertiary teaching hospitals in Saudi Arabia, as well as to evaluate the level of association between moral distress and turnover.
This cross-sectional study, which employed an anonymous 21-item Moral Distress Scale, was undertaken at a large medical institution located in different regions of Saudi Arabia. The data were analyzed using bivariate analyses, and logistic regression.
Of the 342 participants, 239 (69.9%) were nurses/staff physicians and 103 (30.1%) were fellows/consultants. Approximately 24.3% of respondents experienced severe moral distress, whereas 75.7% reported mild moral distress. There was no statistically significant difference between men and women in terms of moral distress. Age was found to be a notable factor: moral distress was significantly higher in those younger than 37 years compared to those 37 years and older (
=0.015). Less than half of the participants (137, 42.8%) indicated their willingness to leave their jobs. A significant association was observed between severe moral distress and leaving the career (OR=3.16;
<0.01). Job category was also an important factor: nurses/staff physicians were almost two times more likely (OR =1.95,
=0.038) to leave their positions compared to fellows/consultants.
This study revealed that moral distress, which is a serious problem that compromises the well-being of caregivers, was a predictive variable for the intention of healthcare providers to leave their jobs. Therefore, it should be routinely examined, and efficient action plans should be implemented to alleviate its consequences.
Total knee arthroplasty (TKA) is a commonly performed surgery for individuals experiencing advanced knee osteoarthritis. Patients undergoing TKA can present with a variety of comorbidities, ranging ...from the absence of chronic illnesses to the presence of multiple health conditions. The complexity of these comorbidities can pose challenges in carrying out the desired procedure due to the elevated risk profile; this limits the anesthesia modalities that the physician can utilize. Careful consideration of patients' overall health status and personalized anesthesia approaches are crucial to ensure optimal outcomes in this diverse patient population. This case involves an eighty-year-old male with a history of multiple comorbidities who underwent a left TKA. The patient presented a high-risk profile during evaluation, classified as American Society of Anesthesiology (ASA) class IV, which made general and neuraxial anesthesia unfavorable due to high risks. Regional anesthesia was utilized as the sole modality of anesthesia and was successful. This demonstrates that regional anesthesia is a viable option when attending to patients with high risks associated with other anesthesia modalities.
Background
Busulfan is an antineoplastic drug that is used widely as part of a conditioning regimen in pediatric patients undergoing hematopoietic stem cell transplantation. It has a narrow ...therapeutic index and highly variable pharmacokinetics; therefore therapeutic drug monitoring is recommended to optimize busulfan dosing.
Objective
To study the population pharmacokinetics of busulfan in Saudi pediatric patients to optimize its dosing.
Settings
King Abdullah Specialist Children’s Hospital in Riyadh, Saudi Arabia.
Methods
This pharmacokinetic observational study was conducted between January 2016 and December 2018. All pediatric patients receiving IV busulfan and undergoing routine therapeutic drug monitoring were included. Population pharmacokinetics modeling was conducted using Monolix2019R1. Pharmacokinetic data of busulfan in children.
Results
The study included 59 patients and 513 samples. The mean ± SD age was 6.10 ± 3.17 years, and the dose administered was 0.994 ± 0.15 mg/kg. The mean ± SD Cmax and area under the curve (AUC) were 900.60 ± 402.8 ng/mL and 1031.14 ± 300.75 µM min, respectively. Based on our simulations, the European Medicines Agency recommended dose were adequate for most patient’s groups to achieve the conventional target of an AUC
0–tau
of 900–1350 µM min. For patients in the lower weight group < 9 kg, higher doses were need at 1.2 mg/kg. With regards to the newly proposed target of AUC 78–101 mg h/mL, all of the doses we tested had low probability of achieving it.
Conclusions
Most of our patients had less than a proportional increase in busulfan concentration suggesting autoinduction. The high interindividual variability and autoinduction make dose adjustments challenging and AUC at steady state difficult to predict from the first dose. One approach to improve dose predictions is to use Bayesian dosing software. Based on our simulations, the European Medicines Agency recommended doses were adequate for most patient groups, except those in the lower (< 9 kg) and higher weight groups (> 34 kg).
Abstract
This study aimed to assess the potential impact of implementing an electronic alert system (EAS) for systemic inflammatory syndrome (SIRS) and sepsis in pediatric patients mortality. This ...retrospective study had a pre and post design. We enrolled patients aged ≤ 14 years who were diagnosed with sepsis/severe sepsis upon admission to the pediatric intensive care unit (PICU) of our tertiary hospital from January 2014 to December 2018. We implemented an EAS for the patients with SIRS/sepsis. The patients who met the inclusion criteria pre-EAS implementation comprised the control group, and the group post-EAS implementation was the experimental group. Mortality was the primary outcome, while length of stay (LOS) and mechanical ventilation in the first hour were the secondary outcomes. Of the 308 enrolled patients, 147 were in the pre-EAS group and 161 in the post-EAS group. In terms of mortality, 44 patients in the pre-EAS group and 28 in the post-EAS group died (
p
0.011). The average LOS in the PICU was 7.9 days for the pre-EAS group and 6.8 days for the post-EAS group (
p
0.442). Considering the EAS initiation time as the “zero time”, early recognition of SIRS and sepsis via the EAS led to faster treatment interventions in post-EAS group, which included fluid boluses with median (25th, 75th percentile) time of 107 (37, 218) min vs. 30 (11,112) min,
p
< 0.001) and time to initiate antimicrobial therapy median (25th, 75th percentile) of 170.5 (66,320) min vs. 131 (53,279) min,
p
0.042). The difference in mechanical ventilation in the first hour of admission was not significant between the groups (25.17% vs. 24.22%,
p
0.895). The implementation of the EAS resulted in a statistically significant reduction in the mortality rate among the patients admitted to the PICU in our study. An EAS can play an important role in saving lives and subsequent reduction in healthcare costs. Further enhancement of systematic screening is therefore highly recommended to improve the prognosis of pediatric SIRS and sepsis. The implementation of the EAS, warrants further validation in multicenter or national studies.
The spin angular momentums of surface plasmon polaritons (SPPs) on chiral material interfaces and the Imbert–Fedorov shifts of linearly polarized light beams are investigated. Compared to a ...traditional TM-polarized SPP having a transverse spin, the SPP on a chiral material interface also has a longitudinal spin component, resulting from the nature that this new kind of SPP is a hybrid of TE and TM-polarized evanescent waves. When a light beam is incident on a sandwich structure composed of chiral material, prisms, and metal layers, in which the SPP is supported, the reflection and transmission processes can be analogous to the transport of a photon in a waveguide QED system. The SPP with longitudinal spin can be excited by the incident wave and the reflected and transmitted beams carry the spin features of the SPP. Moreover, the beams exhibit large Imbert–Fedorov shifts stemming from the spin–orbit coupling even for a linearly polarized incident beam. The shifts are determined by the longitudinal spin angular momentum and excitation coefficient of the SPP. This present work extends the study of photonic spin–orbit coupling and provides an important platform to investigate the plasmonic spin.
This study presents a novel approach to enhance expert panel discussions in a medical conference through the use of ChatGPT-4 (Generative Pre-trained Transformer version 4), a recently launched ...powerful artificial intelligence (AI) language model. We report on ChatGPT-4's ability to optimize and summarize the medical conference panel recommendations of the first Pan-Arab Pediatric Palliative Critical Care Hybrid Conference, held in Riyadh, Saudi Arabia. ChatGPT-4 was incorporated into the discussions in two sequential phases: first, scenarios were optimized by the AI model to stimulate in-depth conversations; second, the model identified, summarized, and contrasted key themes from the panel and audience discussions. The results suggest that ChatGPT-4 effectively facilitated complex do-not-resuscitate (DNR) conflict resolution by summarizing key themes such as effective communication, collaboration, patient and family-centered care, trust, and ethical considerations. The inclusion of ChatGPT-4 in pediatric palliative care panel discussions demonstrated potential benefits for enhancing critical thinking among medical professionals. Further research is warranted to validate and broaden these insights across various settings and cultures.
Cardiac remodeling in rheumatic mitral stenosis (MS) is complex and incompletely understood. The objective of this study was to evaluate cardiac structural and functional changes in a cohort of ...patients with rheumatic MS using cardiovascular magnetic resonance (CMR).
This retrospective study included 40 patients with rheumatic MS, consisting of 19 patients from India, 15 patients from China, and 6 patients from Mexico (median (interquartile range (IQR)) age: 45 years (34-55); 75% women). Twenty patients were included in the control group. CMR variables pertaining to morphology and function were collected. Late gadolinium enhancement (LGE) sequences were acquired for tissue characterization. Statistical analyses were performed using the Kruskal-Wallis test and the chi-square test.
Compared to the control group, patients with MS had lower left ventricular (LV) ejection fraction (51% (42%-55%) vs 60% (57%-65%), p < 0.001), lower right ventricular (RV) ejection fraction (44% (40%-52%) vs 64% (59%-67%), p < 0.001), higher RV end-diastolic volume (72 (58-87) mL/m
vs 59 (49-69) mL/m
, p = 0.003), larger left atrial volume (87 (67-108) mL/m
vs 29 (22-34) mL/m
, p < 0.001), and right atrial areas (20 (16-23) cm
vs 13 (12-16) cm
, p < 0.001). LGE was prevalent in patients with rheumatic MS (82%), and was commonly located at the RV insertion sites. Furthermore, the patient cohorts from India, China, and Mexico were heterogeneous in terms of baseline characteristics and cardiac remodeling.
Our findings demonstrated that biventricular dysfunction, right and left atrial remodeling, and LGE at the RV insertion sites are underappreciated in contemporary rheumatic MS. Further studies are needed to elucidate the prognostic implications of these findings.
Continuous renal replacement therapy (CRRT) has become the preferred mode of dialysis to support critically ill children with acute kidney injury. However, there are limited pediatric data on CRRT ...use, especially in our region.
Determine the outcome of CRRT among critically ill children.
Retrospective cohort study.
Pediatric intensive care unit.
The study included critically ill children 1-14 years of age who underwent CRRT from July 2009 to June 2015. We report the underlying diagnosis, demographics, indications and modality of CRRT, and associated risk factors. Statistical analyses were used to identify risk factors associated with mortality.
Mortality and associated risk factors with use of CRRT.
96 RESULTS: The mean age was 6.0 (standard deviation, 4.4) years, with a male preponderance in the age group from 1-10 years which comprised almost 60% of the study group. The most common primary diagnoses were malignancies 37.5% (36/96) followed by primary renal diseases 19.8% (19/96), and immunodeficiency 16.7% (16/96). The most common indication for CRRT was fluid overload 67.2% (65/96) followed by tumor lysis syndrome 18.8%(18/96), and metabolic encephalopathy 9.4%(9/96). The median length of CRRT was 66 hours (IQR, 35.5-161.4), with a median average circuit life of 30.9 hours (IQR, 16.4-45.0). The most common CRRT catheter site was the internal jugular vein 77.1% (74/96), followed by the femoral vein 18.8%(18/96) with continuous venovenous hemodiafiltration 82.3%(79/96) being the most common CRRT modality used. The mortality rate among critically ill children requiring CRRT was 50% (48/96). There was an increased mortality rate among children with hematological diseases (100%, 10/10), immunodeficiency (86.6%, 13/16) and in children who had undergone stem cell transplantation (90.0%, 27/30), with the least mortality in primary renal disease (15.8% (3/19). We identified septic shock and use of inotropic support as being independently associated with mortality in a multivariate analysis.
The overall mortality rate among critically ill children who un.derwent CRRT was 50% with significantly increased mortality among patients with hematological diseases, immunodeficiency, and in children who had undergone stem cell transplantation. Septic shock and use of inotropic support were associated with mortality.
Retrospective and single center data that is not generalizable.
None.
Background: Primary care physicians are crucial in identifying SARS-CoV-2 infection and transferring suspected cases since they are on the front lines of health care. Micronutrients are used as an ...adjunctive treatment for viral respiratory infections. Because there is currently no effective antiviral therapy for COVID-19, micronutrients such as iron, zinc, and vitamin D may be important for the survival of critically ill patients. Objective: To establish and emphasize a relationship between iron, zinc, and vitamin D to COVID-19. Materials and Methods: PubMed database was used for articles selection. All relevant articles to our review with the topics regarding the use of iron, zinc and vitamin D in COVID-19 patients. We excluded other articles, which are not related to this field and did not match inclusion criteria. The data extracted according to specific form and double reviewed by the group members. Results: The search of the mentioned database returned a total of 3614 studies that were included for title screening. 2910 of them were included for abstract screening, which lead to the exclusion of 1064 articles. The remaining 1846 publications full texts were reviewed. The full-text revision led to the exclusion of 1812 studies, and 34 were enrolled for final data extraction. Conclusion: This study raised the idea of employing zinc, iron, and vitamin D as ingredients to either protect SARS-CoV-2 patients or to speed up recovery, decrease symptoms severity and decrease mortality rates.
Purpose
To assess the effect of gadobenate dimeglumine on magnetic resonance cholangiopancreatography (MRCP) and determine an appropriate time frame for performing MRCP sequences.
Materials and ...methods
2D MRCP sequences obtained after intravenous administration of gadobenate dimeglumine or gadobutrol over 14 months were reviewed retrospectively in randomized order by five abdominal radiologists, using a 3-point scale to rate biliary and pancreatic duct clarity (1 = no-, 2 = limited-, 3 = good visualization). Intraclass correlation coefficients were computed and mean scores were compared for both agents. For gadobenate dimeglumine exams, time delays between arterial phase and MRCP acquisition times were analyzed concerning duct clarity. For gadobutrol, only exams with delays ≥ 15 min were included.
Results
134 exams (107 gadobenate dimeglumine, 27 gadobutrol) were included. Moderate reliability for pancreatic duct visualization and excellent reliability for visualization of intrahepatic bile ducts and upper and lower extrahepatic bile ducts were noted. No difference in mean scores was noted for pancreatic duct visualization (
p
= 0.66). Bile duct segment scores were lower with gadobenate dimeglumine (mean: 2.1–2.6) compared with gadobutrol (mean: 2.8–2.9) (
p
≤ 0.006). For gadobenate dimeglumine, visualization scores varied depending on the delay between the arterial phase and MRCP acquisition (
p
≤ 0.047). Good visualization for all bile duct segments was noted with delays of 7.2–9.4 min (95% confidence interval; mean 8.3 min).
Conclusion
Bile duct clarity degraded on MRCP images with an increasing delay following gadobenate dimeglumine injection. 2D MRCP, thus, should be performed within 7.2 min after obtaining the arterial phase sequence to ensure good visualization of the entire biliary system.
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