Hepatoprotective effects of metformin in hepatitis C virus-infected adolescents with beta thalassemia major Dear Editor;We read the recently published article by Abdel Monem et al.1 with great interest. The authors reported that metformin in antiviral naïve adolescents with beta thalassemia major (β-TM) infected with hepatitis C virus (HCV), can improve oxidative stress, as well as liver fibrosis, transaminases, and some symptoms. They proposed metformin as an option for its hepatoprotective effects in these patients until the initiation of antiviral agents.Repeated transfusions expose patients with thalassemia to HCV infection2. Although cirrhosis and hepatocellular carcinoma are infrequent in children with this infection, in patients with thalassemia the presence of iron overload can increase the likelihood of progression of liver fibrosis 3. So, the idea of using hepatoprotective agents in these patients seems appealing. Based on the importance of the issue, we think several points regarding the article are worth to be discussed.Abdel Monem et al. included “HCV-infected β-TM patients” in their study. However, the diagnosis of HCV was based only on detecting anti-HCV antibody. Although spontaneous clearance of HCV infection in patients with thalassemia occurs less compared with patients without thalassemia, there is still a chance for it 4. Hence, the interpretation of a positive HCV antibody test and differentiation of current infection from a resolved infection, or even a false-positive result 5 is not possible. Indeed, it is emphasized to confirm the diagnosis of HCV in patients with positive anti-HCV antibody, with detecting viremia 6.Moreover, the study record in the registry of clinical trials raises questions regarding the inclusion criteria. The authors addressed the ClinicalTrials.gov registration number of NCT02984475. The inclusion criteria of the registered trial are patients with thalassemia regardless of their HCV serostatus. It is quite informative for the audiences if the authors elaborate on why the inclusion criteria have changed.In the study, the score of liver stiffness and fibrosis grade were investigated by FibroScan. In table 3, changes in liver stiffness score for 30 patients in the control group and 27 patients in the metformin group were shown. However, for the fibrosis grade at baseline (table 1) and its changes (figure 4), only the data of 26 and 25 patients in the control and metformin group were presented, respectively. Since both parameters were assessed with the same scan, it was presumed to have the data of the same number of patients for liver stiffness score and fibrosis grade.In the method section, it was mentioned that randomization of the patients into two groups was based on 1:1 allocation. Thus, within the 60 patients randomized, it was assumed to have two groups of 30 participants. However, the control and the placebo group included 31 and 29 patients, respectively.Among the participants, there were 12 patients with liver fibrosis of grade ≥ 3 at baseline. Moreover, in 19 patients, the grade of liver fibrosis deteriorated at the end of the study. So, deciding to postpone the initiation of antiviral treatment seems to be discussable. The authors mentioned that during the recruitment after the approval of direct acting antivirals (DAAs) if patients “had the chance to receive antiviral treatment” they could leave the study. As shown in figure 1, there was only one patient who left the study for this reason. It is not clear what the chance of receiving antiviral treatment depended on. It should be noted that even before the era of DAAs, there was evidence supporting the treatment of patients with β-TM and HCV with pegylated interferon and ribavirin 7-9.Author Contributions: Both authors contributed in the concept and drafting the manuscriptFunding: NoneAcknowledgements; NoneDisclosures: The authors declare that they have no conflict of interest.References:1. Abdel Monem MS, Farid SF, Abbassi MM, et al. The potential hepatoprotective effect of metformin in hepatitis C virus‐infected adolescent patients with beta thalassemia major: Randomised clinical trial. International Journal of Clinical Practice. 2021:e14104.2. Daher HB, Sharara AI. Treatment of Chronic HCV Infection in Patients With Thalassemia. Clinical liver disease. 2019;14(6):199.3. Spearman CW, Dusheiko GM, Hellard M, et al. Hepatitis C.Lancet . 2019; 394: 1451–14664. Kamal S, Abdelhakam S, Ghoraba D, et al. The course of hepatitis C infection and response to anti-viral therapy in patients with thalassemia major and hepatitis C infection: a longitudinal, prospective study. Mediterranean journal of hematology and infectious diseases. 2019;11(1).5. Squires JE, Balistreri WF. Hepatitis C virus infection in children and adolescents. Hepatology communications. 2017;1(2):87-98.6. Ghany MG, Morgan TR, panel AIhCg. Hepatitis C guidance 2019 update: American Association for the Study of Liver Diseases–Infectious Diseases Society of America recommendations for testing, managing, and treating hepatitis C virus infection. Hepatology.2020;71(2):686-721.7. Di Marco V, Capra M, Angelucci E, et al. Management of chronic viral hepatitis in patients with thalassemia: recommendations from an international panel. Blood, The Journal of the American Society of Hematology. 2010;116(16):2875-2883.8. Aminizadeh E, Alavian SM, Sari AA, Daryani NE, Behnava B. Safety and efficacy of adding ribavirin to interferon or peginterferon in treatment of hepatitis C infection in patients with thalassemia: a systematic review on randomized controlled trials. Hepatitis monthly.2016;16(3).9. Borgna-Pignatti C, Gamberini MR. Complications of thalassemia major and their treatment. Expert review of hematology.2011;4(3):353-366.

Objective: The current study aimed to evaluate eye care needs along with ocular findings in patients treated in intensive care units due to Covid-19 infection. Materials and Methods: A total of 93 patients, 58 men and 35 women, who were under follow-up and treatment in intensive care due to COVID-19 infection between 01/01/2021 and 02/15/2021 were included in the study. Detailed eye examinations of the patients were performed with a portable handheld biomicroscope and direct and indirect ophthalmoscope. Cases requiring treatment for eye diseases were identified and treated. Results: The mean patient age was 68.32 ± 9.97 years; 35 patients were followed-up and treated with non-invasive mechanical ventilation and 58 patients with invasive mechanical ventilation support. Mild, moderate, and severe chemosis was observed in 19 patients (20.4%), 10 patients (10.8%), and 4 patients (4.3%), respectively. Conjunctivitis (8.6%) was observed in 8 patients. Corneal abrasion was present in 7 patients (7.5%). Keratitis secondary to exposure keratopathy was observed in one patient. Eye care and medical treatment was initiated for these patients. We noted 8 patients (8.6%) with retinal haemorrhage; however, to the best of our knowledge, these patients may show acute retinal involvement secondary to systemic diseases or have previous retinal findings other than Covid-19 infection or treatments. Conclusion: Findings of ocular involvement due to COVID-19 infection were detected in the present study. Retinal haemorrhages were detected in addition to the common findings in viral infections. Especially in patients supported with mechanical ventilation, the detection and treatment of conditions that require eye care for exposure keratopathy is very important for recovering from the disease and the quality of vision.

Background: Cognitive impairment is very common in patients with hypertension, it’s necessary to conduct a meta-analysis to evaluate the association of cognitive function and blood pressure variability in patients with hypertension, to provide insights into the clinical management of hypertension and cognitive impairment. Methods: We searched PubMed et al databases for the case-control studies on the association between blood pressure variability and cognitive function up to July 15, 2021. Two researchers independently screened the literature and retrieved the data. RevMan 5.3 was used for data meta-analysis Results: A total of 13 studies involving 2754 patients were included. Meta-analysis indicated that 24-hour systolic [MD= 3.54, 95% CI (2.48, 4.60)] and diastolic [MD=2.43, 95%CI (1.55, 3.31)] blood pressure variation coefficient in the CI group were significantly higher than that of no CI group (all P<0.05). Standard deviation of systolic [MD=2.20, 95% CI (0.27, 4.13)] and diastolic [MD=1.79, 95% CI (0.80, 2.79)] blood pressure variation in the CI group were significantly higher than that of no CI group (all P<0.05). Mean systolic [MD=3.73, 95% CI (0.92, 6.53)]and diastolic [MD = 5.41, 95% CI (0.42, 10.40)] blood pressure variation in the CI group were significantly higher than that of no CI group (all P<0.05). There were no statistically significant differences in the morning peak systolic [MD=7.85,95% CI (-1.30,17.01)] and diastolic [MD=4.44,95% CI (-6.00, 14.89)] blood pressure drop between the CI group and no CI group(all P>0.05). Conclusion: Cognitive impairment in hypertensive patients is closely associated with increased blood pressure variability, and clinical medical staff should pay attention to the management of blood pressure variability in hypertensive patients to reduce the development of cognitive impairments.

Introduction: The current study aims to evaluate the relationship between C-reactive protein (CRP) levels, thorax CT findings and CT-SS in patients presenting to the emergency department with COVID-19. Methods: Patients diagnosed with COVID-19 by nasopharyngeal rt-PCR (+) in the emergency department were included in the study. In addition to the CRP, ferritin and D-dimer examinations of patients at admission, thorax CT involvement findings and CT-SS results were recorded. The relationship of CRP value with CT-SS and clinical outcome was evaluated. Results: A total of 974 COVID-19 patients, 572 males (58.7%) and 402 females (41.3%), with a mean age of 59.64±17.34 years, were included in the study. The CRP values of the patients who needed intensive care and needed respiratory support were also significantly higher at admission (95.1 mg/dL vs. 31.05 mg/dL) (p<0.001). The CRP values of the patients who developed any complications during the treatment of COVID-19 were higher (79.9 mg/dL vs. 41.85 mg/dL) (p<0.001). In the case of CRP >124.5, a thorax CT density score 7.35 times higher was determined to be severe. In addition, it was determined that there was a 9.09-fold increase in the incidence of negative imaging findings in terms of COVID-19 in cases where the CRP value was <12.5 mg/dL. Conclusion: The CRP levels of COVID-19 patients measured upon admission to the emergency room are correlated with the severity of lung involvement and are an important predictor of clinical outcomes.

Dear editor, we read with great interest the well written article by Dr Kerget et al with the main objective of investigating the role of TREM-1/TREM-2 ratio on patients with COVID-19 pneumonia. The article pointed that TREM-1 and TREM-2 have important role in inflammation and TREM-1/TREM-2 ratio was higher in severe COVID-19 patients compared with moderate COVID-19 patients. We have certain comments to understand the conclusions of this article. Firstly, triggering receptor expressed on myeloid cells-1 (TREM-1) is mainly express on neutrophils and monocytes in a cell membrane-bound form. A soluble form of TREM-1(sTREM-1), which lacks the cytoplasmic tail and transmembrane part, were detected in the blood in recent studies. Since you have mentioned “serum TREM-1”, we were confused whether you detected TREM-1 or sTREM-1. Secondly, we wanted to know more about the treatment and the kidney functions of the patients. Thirdly, We are curious to see if high TREM-1/TREM-2 ratio could predict the distribution of ILD. We would be glad to hear the opinion of the author on the points, to get a more convincing conclusion.

Introduction Some levothyroxine unresponsive individuals with hypothyroidism are prescribed a Natural Desiccated Thyroid (NDT) preparation such as Armour Thyroid® or ERFA Thyroid®. These contain a mixture of levothyroxine and liothyronine in a fixed ratio. We evaluated the response to NDT in individuals at a single endocrine centre in terms of how the change from levothyroxine to NDT impacted on their lives in relation to quality of life (QOL) and thyroid symptoms. Methods The ThyPRO39 (thyroid symptomatology) and EQ-5D-5L-related QoL)/EQ5D5L (generic QOL) questionnaires were administered to 31 consecutive patients who had been initiated on NDT, before initiating treatment/6 months later. Results There were 28women/3men. The dose range of NDT was 60mg-180mg daily. Age range was 26-77 years with length of time since diagnosis with hypothyroidism ranging from 2-40 years. One person discontinued the NDT because of lack of response; 2 because of cardiac symptoms. EQ-5D-5L utility increased from a mean (SD) of 0.214 (0.338) at baseline, to 0.606 (0.248) after 6 months; corresponding to a difference of 0.392 (95% CI 0.241-0.542), t=6.82, p<0.001. EQ-VAS scores increased from 33.4 (17.2) to 71.1 (17.5), a difference of 37.7 (95%CI 25.2-50.2), t=-4.9, p<0.001. ThyPRO scores showed consistent fall across all domains with the composite QoL-impact Score improving from 68.3 (95%CI 60.9-75.7) to 25.2 (95%CI 18.7-31.7), a difference of 43.1 (95%CI 33. -53.2) (t=5.6, p<0.001). Conclusion Significant symptomatic benefit and improvement in QOL was experienced by people with a history of levothyroxine unresponsive hypothyroidism, suggesting the need for further evaluation of NDT in this context.

Background: Transrectal ultrasound biopsy is the preferred method for diagnosing prostate cancer, but it can cause infectious complications as a result of fluoroquinolone resistance. We aimed to explore the potential protective effect of a second rectal enema before biopsy. Methods: Between January 2015 and December 2020, 419 patients were assessed retrospectively. Patients with a history of anticoagulant use, uncontrolled diabetes, urological surgery, prostate biopsy, or recent hospitalization or overseas travel, as well as those with previous prostatitis, were excluded from the study. The patients were subsequently divided into two groups: Group 1 (n=223) had received one enema, on the morning of the biopsy, and Group 2 (n=196) had received two, with the additional enema administered half an hour before the procedure. Results: There was no significant difference between the groups in terms of age, BMI, diabetes, prostate-specific antigen (PSA) level, and prostate size (p=0.076, p=0.489, p=0.265, p=0.193, and p=0.661, respectively) or in relation to cancer detection (p=0.428). The median hospitalization date was significantly higher in Group 1 (p=0.003) as was UTI development (p=0.004). However, there was no significant difference in terms of fever and sepsis (p=0.524 and p=0.548, respectively). Additionally, subgroup analysis demonstrated that UTI was significantly lower in patients with diabetes mellitus who had received a second enema (p=0.004), though there was no significant difference in UTI between the groups in those without diabetes mellitus (p=0.215). Multivariable analysis showed that age and diabetes were significant risk factors for the development of UTI (p=0.002andp=0.003, respectively). Furthermore, the second enema was a significant protective factor for preventing UTI (p<0.001). Conclusion: Older age and the presence of diabetes mellitus are independent risk factors for UTI after prostate biopsy. A second enema procedure before biopsy may protect patients from related infectious complications and could therefore be used as an alternative preventative method.

We read with interest the aforementioned paper by Al-Zubayer et al. 20211 that investigated the “double” and “triple” burden of non-communicable diseases defined as any two or three of hypertension, diabetes and overweight/obesity, respectively. When the prevalence of individual condition was examined it was found that “Almost 56% had hypertension, 23.4% had diabetes and 24.6% had overweight or obesity”.We think the authors have made errors in their analysis that has resulted in unreliable prevalence estimates of hypertension, diabetes and overweight/obesity, and casting doubt on their estimates of burden of non-communicable diseases. This will cause confusion in the scientific and wider community and at worst, inappropriate allocation of resources to address the artificially elevated burden of diseases. We have identified errors related to the calculation of mean blood pressure, definition of diabetes, and classification of overweight/obesity, as outlined below.Al-Zubayer et al. 2021 state that “interviewers have measured the respondents’ blood pressure and it was taken at the beginning, in the middle and at the end of each interview. The mean value of these measurements was documented as the final result to measure hypertension1”. The Bangladesh Demographic and Health Survey (BDHS) survey did measure blood pressure three times, however, the report states that “The average of the second and third measurements was used to report respondents’ blood pressure values”2. This is a standard practice in research and clinical practice to reduce the possibility of ‘white coat’ hypertension from the first reading. The classification of hypertension based on the mean of all three measurements may have resulted in higher means, and an overestimate of the prevalence of hypertension.The authors also state that “If the fasting plasma glucose values were >6.1 mmol/L (110 mg/dL) and/or taking any medicine for diabetes, then the participant is considered to be diabetic otherwise normal.”1 However, this is an incorrect definition of diabetes because it includes pre-diabetes . Fasting blood glucose in the range 6.1 to 6.9 mmol/L is the level for pre-diabetes, as recommended by the WHO3. It is also not the classification used in the BDHS survey report which states that “Individuals were considered as having raised blood glucose or diabetes if they had a fasting blood glucose (FBG) equivalent level of 7 mmol/L or above at the time of the survey or reported currently taking prescribed medication for their high blood glucose or diabetes”2, which is consistent with the WHO classification3. As a result of including prediabetes, the prevalence of ‘diabetes’ reported by the authors (23.4%) was more than double that reported in the BDHS survey report (10%)2.Al-Zubayer et al. 2021 used the WHO global cut-off for overweight/obesity (BMI ≥25kg/m2). However, we think it would have been more appropriate to use Asian cut-offs (BMI ≥23kg/m2) as suggested by the WHO expert consultation4. This is due to the high risk of type 2 diabetes and cardiovascular disease in Asian people at lower BMIs than the WHO global cut-offs4.We believe these are important misinterpretations, which need to be addressed by the authors.

Abstract: Background: Gastrointestinal complications of this COVID-19 have been reported over the last year. One such manifestation is bowel ischemia. This study thus aims to provide a more holistic review of our current understanding of COVID-19 induced bowel ischemia. Method and Results: A meticulous search was performed using different keywords in PubMed, EMBASE, and Google Scholar. Fifty-two articles were included in our study after applying inclusion and exclusion criteria and performing the qualitative assessment of the studies. A total of 25,702 patients were included in our study after the completion of the qualitative assessment. Discussion: COVID-19 commonly presents in the GIT as diarrhea, vomiting, and nausea. The mechanism of bowel ischemia is associated with the formation of emboli which is related to COVID-19’s high affinity for angiotensin-converting enzyme-2 on enterocytes, affecting the superior mesenteric vessels. Clinically, patients presented with abdominal pain and vomiting. CT angiography of the abdomen and pelvis showed acute mesenteric ischemia. Management was usually initiated with gastric decompression, fluid resuscitation, and hemodynamic support. Surgical intervention was also sought. Conclusion: Mesenteric ischemia presenting in patients with COVID-19 has to be considered when symptoms of severe abdominal pain are present. More research and guidelines are required to be able to triage patients with COVID-19 to suspect mesenteric ischemia and to help in diagnosis and management.

Introduction: Guidelines recommend using a pulse oximeter rather than arterial blood gas (ABG) for COVID-19 patients. However, significant differences can be observed between oxygen saturation measured by pulse oximetry (SpO2) and arterial oxygen saturation (SaO2) in some clinical conditions. We aimed to assess the reliability of pulse oximeter in patients with COVID-19 Methods: We retrospectively reviewed ABG analyses and SpO2 levels measured simultaneously with ABG in patients hospitalized in COVID-19 wards. Results: We categorized total 117 patients into two groups; in whom the difference between SpO2 and SaO2 was 4% (acceptable difference) and >4% (large difference). Large difference group exhibited higher neutrophil count, C-reactive protein, ferritin, fibrinogen, D-dimer and lower lymphocyte count. Multivariate analyses revealed that increased fibrinogen, increased ferritin and decreased lymphocyte count were independent risk factors for large difference between SpO2 and SaO2. The total study group demonstrated the negative bias of 4.02% with the limits of agreement of −9.22% to 1.17%. The bias became significantly higher in patients with higher ferritin, fibrinogen levels and lower lymphocyte count. Conclusion: Pulse oximeters may not be sufficient to assess actual oxygen saturation especially in COVID-19 patients with high ferritin and fibrinogen levels and low lymphocyte count low SpO2 measurements.

Aim of the study: Subconjunctival hemorrage (SCH) is a frequent bleeding manifestation and a common cause of visits to the primary care. Trauma in young patients and vascular damage such as hypertension in the elderly are the most common causes of SCH and the prevalence of hematological diseases is less than 1%. We aimed to evaluate the prevalence of congenital or acquired bleeding disorders in patients with once or recurrent SCH. Methods used to conduct the study: It is a retrospective study and included fifty-two patients with SCH whose etiologic factor was not detected. Hemostatic tests were studied in 52 patients (25 male and 27 females). All patients included were evaluated for congenital or acquired bleeding disorder and SCH with once and those with 2 or more were compared for the laboratory results. Results of the study: Type I von Willebrand disease (vWD) was diagnosed in one patient with recurrent SCH and one patient with single SCH (3.8%). The prevalence of patients with type 1 vWD in the study was not statistically significant when compared with the frequency of vWD in the normal population. Fibrinogen level was found to be statistically higher in patients who had SCH once than those who had recurrent SCH. But fibrinogen level was in normal range in all patients. Conclusions drawn from the study and clinical implications: There was no increase in the incidence of congenital or acquired bleeding disorder in SCH compared to normal population. For this reason it was thought that there was no need for evaluation for bleeding disorders in spontaneous SCH.

Aim: In this study, we aimed to define the predictive role of liver function tests at admission to the hospital in outcomes of hospitalized patients with COVID-19. Material and Method: In this multicentric retrospective study, a total of 269 adult patients (≥18 years of age) with confirmed COVID-19 who were hospitalized for the treatment were enrolled. Demographic features, complete medical history, and laboratory findings of the study participants at admission were obtained from the medical records. Patients were grouped regarding their ICU requirements during their hospitalization periods. Results: Among all 269 participants, 106 were hospitalized in the intensive care unit (ICU) and 66 died. The patients hospitalized in ICU were older than patients hospitalized in wards (p=0.001) and expired patients were older than alive patients (p=0.001). Age, elevated serum D-dimer, creatinine, and gamma-glutamyl transferase (GGT) levels at admission were independent factors predicting ICU hospitalization and mortality in COVID-19 patients. Conclusion: In conclusion, in hospitalized patients with COVID-19, laboratory data on admission, including serum, creatinine, GGT and d-dimer levels have an important predictive role for the ICU requirement and mortality. Since these tests are readily available in all hospitals and inexpensive, some predictive formulas may be calculated with these parameters at admission, to define the patients requiring intensive care.

Background: Many different internal factors have been proven to influence urine production such as age, weight, and quality of sleep. External factors such as consumption of caffeine and fluid consumption have been shown to have an impact on urine production. Aim: To investigate the impact of movement, physical activity, and position on urine production. Methods: This prospective observational study was executed at Ghent University Hospital, Belgium. Study participation was open for anyone visiting the hospital. Participants collected 1 basic and 2 extended 24-hour urine collections and filled in questionnaires concerning their general health and physical activity. Urinary levels of osmolality, sodium, and creatinine were determined. Data on movement, physical activity and position was described. Results: An increase in body movement leads to a significant increase in diuresis during daytime, night-time, and 24 hours (p=0,002, p= <0,001, and p=<0,001, respectively). An increase in body movement leads to a significant decrease in osmolality during night-time and 24 hours (p=0,009, and p=0,004, respectively). However, no significant influence of movement on osmolality was found during daytime (p=0,12). An increase in body movement leads to a significant decrease in creatinine during daytime, night-time, and 24 hours (p=0,001, <0,001, and p=<0,001, respectively). An increase in body movement leads to a significant increase in sodium during daytime (p=0,046) but this was statistically significant during night-time and 24 hours (p=0,32, and p=0,84 respectively). Conclusion: Our study demonstrates a statistically significant association of movement, physical activity, and position with urine production. It would therefore be interesting to explore this association further with the use of new technology to have more accurate data. Here lays a potential role for conservative measurements and lifestyle adaptations in the management of patients with bothersome LUTS and more precisely nocturia.

Objective: No effective treatment has yet been found for SARS-cov-2, which caused a pandemic outbreak in 2019. It is crucial to detect the progression of Covid-19 in patients as early as possible. Fibrinogen to albumin ratio (FAR) has been used as a new inflammatory marker. We aimed to find out whether the use of the FAR ratio as a predictor of mortality in Covid-19 patients provides clinical benefit. Materials and Methods: Data from 590 patients with Covid-19 from 15/03/2020 to 15/01/2021 in medicine wards and intensive care units (ICU) were retrospectively analyzed. Demographic data and other laboratory markers were collected from the electronic medical records. Relationship between FAR ratio was investigated between patients in the survivor/non-survivor patients. Findings: The mean FAR levels in patients who were non survivor was 24.44±30.3 (n:272 and 11.29±6.29 (n:275) (p:0.000) in patients survivor COVID-19 infection. In ROC curve for FAR, the threshold FAR that may pose a risk for mortality was determined as 13.84 ((AUC: 0.808(0.771-0.844)); 74.9% Sensitivity, 74.6% Specificity; p:0.000 )). Result: As a result of this study, increased FAR were found to be important markers in determining the mortality levels in Covid-19 patients. What is already known about FAR ratio: The fibrinogen albumin ratio is a value that has been used to determine the prognosis, especially in malignancies. [32] In a recent study 91 Covid-19 patients were analyzed 22 patients with severe disease higher FAR ratio compare to mild disaese [36] What does this article add about FAR ratio in Covid-19 patients: It has been concluded that the FAR ratio, which is used in diseases such as malignancy, hypertension, and coronary syndrome as a marker of disease progression, can be used as a mortality indicator in Covid-19

Aim of the study: Hydrocortisone is a soft steroid with low anti-inflammatory properties and a short duration of action, used to manage several ocular conditions. The clinical benefits and side effects associated with hydrocortisone are well documented, but its basic pharmacokinetic in the eye is yet to be fully elucidated. The purpose of this study is to investigate the anterior chamber penetration capabilities of hydrocortisone when used in different concentrations as eye drops treatment. Materials and Methods: This is a double-blind, single-center, randomized clinical trial performed at the Department of Medicine and Surgery of the University of Perugia (Italy) on consecutive patients who have undergone phacoemulsification with intraocular lens implantation. Patients were randomly assigned on the morning of surgery to receive a single instillation of 0.33% (group A) or 0.001% (group B) hydrocortisone sodium phosphate solution. Group of patients C did not receive any treatment and was used to measure the hydrocortisone endogenous levels. Before surgery, one aliquot of aqueous humor for each patient was aspirated. The time of collection for each sample was recorded. Hydrocortisone concentrations were then stratified into six interval classes of 30 minutes each. Results: The mean concentration of hydrocortisone was significantly higher in group A (25.2±12.4 ng/ml) compared with group B (7.11±1.51 ng/ml) and compared to the mean hydrocortisone endogenous levels (3.92±1.18 ng/ml) (p<0.0001). No statistically significant differences of hydrocortisone mean concentrations between group B and the mean endogenous levels were found. Conclusions: Considering the frequent need for prolonged topical steroid therapies and the possible consequent undesirable side effects, ophthalmologists should consider the lowest clinically effective dose of hydrocortisone useful to obtain the desired therapeutic effect and in an adequate time, to minimize the amount of steroids into the anterior chamber and to avoid side effects, such as intraocular pressure increase or cataract development.

Objectives. Fifteen potentially low value practices in adult orthopaedic trauma care were previously identified in a scoping review. The aim of this study was to synthesize the evidence on these practices. Methods. We searched four databases for systematic reviews, randomized controlled trials (RCTs), cohort studies and case series that assessed the effectiveness of selected practices. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal Checklist for Case Series. We evaluated risk of bias with the Cochrane revised tool for RCTs and the risk of bias in non-randomized studies of interventions tool for observational studies. We summarized findings with measures of frequency and association for primary outcomes. Results. Of the 30,670 records screened, 70 studies were retained. We identified high-level evidence of lack of effectiveness or harm for routine initial imaging of ankle injury, orthosis for A0-A3 thoracolumbar burst fracture in patients < 60 years of age, cast or splint immobilization for suspected scaphoid fracture negative on MRI or confirmed fifth metacarpal neck fracture, and routine follow-up imaging for distal radius and ankles fractures. However, evidence was mostly based on studies of low methodological quality or high risk of bias. Conclusion. In this review, we identified clinical practices in orthopedic injury care which are not supported by current evidence and whose use may be questioned. In future research we should measure their frequency, assess practice variations and evaluate root causes to identify practices that could be targeted for de-implementation.

Background: This study was conducted to determine the frequency and clinical features of patients who were diagnosed incidentally as having diabetes mellitus (DM) in the emergency department. Aim: Our aim was to investigate the frequency of DM in patients whose high blood glucose levels were detected, and to examine the subsequent treatment these patients. Methods: The participants were selected from among patients who had a glucose level of ≥200 mg/dL and admitted to emergency department with symptoms of hyperglycemia in the past 1 year. Age, sex, presence of chronic disease, and the laboratory blood parameter results of the patients were recorded. We divided the patients into three groups as those who had never been admitted to clinics for treatment, those who were admitted and given treatment, and not given treatment. Results: According to their sexes, 73 (52.1%) were male and 67 (47.9%) were female. It was determined that 86 of the 140 patients included in the study were admitted to clinics for treatment. It was determined that no medication was given to 50 of these patients, but treatment was initiated in 36. Patients with glucose level ≥300 mg/dL were found to be receiving more treatment significantly (p=0.031). Conclusions: In this study, diabetic patients whose blood sugar is between 200-300 mg/dL should be sent to the DM related clinic immediately when diagnosed in the emergency department.

Background Lack of definitive cure for COVID-19 and the late introduction of a vaccine were responsible to push the general public to look for a remedy to treat or prevent COVID-19. The objective of this study was to evaluate patterns and factors that affect self-medication practices in Jordan during the pandemic. Methods This was a cross-sectional study using an online questionnaire that was developed, piloted and distributed to the general public via various social media platforms. The questionnaire assessed the type of drugs and treatments used to self -medicate, the reasons behind their self- medication, and the factors affecting their practices. Results A total of 1179 participants (females 46.4%) with a mean age of 32 (SD=12.5) completed the questionnaire. The overall prevalence of the use of at least one product to treat or prevent COVID-19 was 80.4 %. The most commonly used products to self-medicate were vitamin C (57.6%), followed by paracetamol (51.9%), zinc (44.8%) and vitamin D (32.5%). Female gender (odds ratio [OR]) = 1.603, working in the medical field (OR =1.697), and history of COVID-19 infection (OR =2.026) were variables associated with self-medication. The most common sources of participants’ information about drugs to prevent or treat COVID-19 were newspapers (n=519, 44.0%), followed by pharmacists (43.4%), friends (33.8%) and internet searching such as Google (30.7%). Conclusion This study identified the main drugs and supplements used during COVID-19 and the motives behind their use. It also identified the most influential source of information on the public during the pandemic. Self-medication can lead to worsening of the patient’s health and delay seeking medical advice from healthcare professionals. Efforts should be done to help mitigate risks of self-medications by active involvement of pharmacists and other members of healthcare team to refute false claims about drug, especially in the media.