Search results for: patient’s rights

Authors: Mojtaba Eshraghi Arani

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According to the international conventions for the carriage of goods by sea, the consignee is the person who is entitled to take delivery of the cargo from the carrier. Such a person is usually named in the relevant box of the bill of lading unless the latter is issued “To Order” or “To Bearer”. However, there are some cases in which the apparent consignee, as above, was not intended to take delivery of cargo, like the L/C issuing bank or the freight forwarder who are named as consignee only for the purpose of security or acceleration of transit process. In such cases as well as the BL which is issued “To Order”, the so-called “real consignee” can be found out in the “Notify Party” box. The dispute revolves around the choice between apparent consignee and real consignee for being entitled not only to take delivery of the cargo but also to sue the carrier for any damages or loss. While it is a generally accepted rule that only the apparent consignee shall be vested with such rights, some courts like France’s Cour de Cassation have declared that the “Notify Party”, as the real consignee, was entitled to sue the carrier and in some cases, the same court went far beyond and permitted the real consignee to take suit even where he was not mentioned on the BL as a “Notify Party”. The main argument behind such reasoning is that the real consignee is the person who suffered the loss and thus had a legitimate interest in bringing action; of course, the real consignee must prove that he incurred a loss. It is undeniable that the above-mentioned approach is contrary to the position of the international conventions on the express definition of consignee. However, international practice has permitted the use of BL in a different way to meet the business requirements of banks, freight forwarders, etc. Thus, the issue is one of striking a balance between the international conventions on the one hand and existing practices on the other hand. While the latest convention applicable for sea transportation, i.e., the Rotterdam Rules, dealt with the comparable issue of “shipper” and “documentary shipper”, it failed to cope with the matter being discussed. So a new study is required to propose the best solution for amending the current conventions for carriage of goods by sea. A qualitative method with the concept of interpretation of data collection has been used in this article. The source of the data is the analysis of domestic and international regulations and cases. It is argued in this manuscript that the judge is not allowed to recognize any one as real consignee, other than the person who is mentioned in the “Consingee” box unless the BL is issued “To Order” or “To Bearer”. Moreover, the contract of carriage is independent of the sale contract and thus, the consignee must be determined solely based on the facts of the BL itself, like “Notify Party” and not any other contract or document.

Keywords: real consignee, cargo, delivery, to order, notify the party

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Authors: Saman Naqvi

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Introduction: Telemedicine is the practise of providing remote healthcare to patients via the utilisation of communication technologies. Its application has become increasingly important since the Coronavirus Disease 2019 (COVID-19) pandemic. It is essential to determine the knowledge and attitudes of healthcare professionals concerning its use in order to maximise its application. Purpose: We aim to examine and evaluate the current understanding and perceptions of medical staff toward the use of telemedicine. Methods: In this cross-sectional study, we surveyed 1091 healthcare professionals worldwide. Following an extensive review of the literature, data were gathered using a questionnaire. To depict the participant profile, frequency, percentages, and cumulative percentages were determined. Results: The majority of respondents had either heard of (90.9%), seen (65.3%), or were familiar with (74.6%) how telemedicine is implemented in practice. 72.2% of people were familiar with the tools that could be applied to this technology. Those with a medical degree and experience of under five years were found to be more familiar with telemedicine. Additionally, opinions on providing healthcare remotely were largely favorable, with 80% of respondents stating that it reduced staff burden and 80.6% thinking that it eliminated unnecessary transportation costs. Furthermore, 83% expressed that it saves clinicians' time. However, 20% of participants believed telemedicine adds to staff workload and 40% of healthcare professionals felt it compromises patient privacy and information confidentiality. Conclusion: Despite being a new and developing practice in many countries, telemedicine appears to have a bright future. This is crucial during a pandemic as it provides effective healthcare while maintaining social isolation measures. Moreover, the majority of the participants in this study demonstrated a good understanding and a favorable attitude toward telemedicine.

Keywords: healthcare system, global survey, knowledge, attitude, covid 19, telemedicine

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Authors: Ishwor Paudel, Pratima Gautam, Sandeep Bhattarai

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Bile spillage occurs frequently during laparoscopic cholecystectomy yet its impact on postoperative outcomes remains unknown. It might not be as innocuous as some surgeons tend to believe and in fact, might be associated with post-operative surgical site infections (SSI). It often leads to patient dissatisfaction, emergency department visits, with subsequent readmission and additional procedures. While some authors found no increase in SSI following bile spillage (BS) compared to non-bile spillage cases, others found bile spillage to be associated with SSI. Therefore we sought to examine whether bile spillage is indeed associated with an increased risk of postoperative wound infections after laparoscopic cholecystectomy. I hypothesize that patients who experience BS during operation, have an increased risk of SSI compared to those who do not. This is a prospective observational study conducted in the Department of Surgery, Patan Hospital over a period of one year. Patients undergoing Laparoscopic cholecystectomy were included and bile spillage, if happened was noted. All cases were followed up for 30 days and SSI was diagnosed as per CDC-defined criteria. Fisher’s test was applied to compare SSI in bile spillage versus non-bile spillage cases. A total of 112 patients were included in the final analysis. Bile spillage occurred in 20 cases and was absent in the rest i.e.92 cases. Among bile spillage cases, SSI was found in 4 cases (20%), whereas in nonbile spillage cases, SSI was found in 8 cases (8.7%). However, it was statistically not significant (p-value>0.05). Eleven (92%) cases were superficial SSI and one was an organ-space infection. No mortality or 30-day readmission. Spillage of Gallbladder content does not lead to an increase in SSIs. However as the rate of SSI is still higher, Surgeons should be careful to avoid iatrogenic gallbladder perforation and in case of bile spillage thorough peritoneal irrigation with normal saline should be done.

Keywords: organ space infection, Laparoscopic cholecystectomy, biliary spillage, surgical site infection

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Authors: Keiko Naito, Y. Nakashima, S. Yamauchi, Y. Kunitani, Y. Ishigami, K. Numata, M. Mizobe, Y. Homma, J. Takahashi, T. Inoue, T. Shiga, H. Funakoshi

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Background: A presence of severe acidemia, defined as pH < 7.2, is common during endotracheal intubation for critically ill patients in the emergency department (ED). Severe acidemia is widely recognized as a predisposing factor for intubation failure. However, it is unclear that acidemic condition itself actually makes endotracheal intubation more difficult. We aimed to evaluate if a presence of severe acidemia before intubation is associated with the lower first attempt intubation success rate in the ED. Methods: This is a retrospective observational cohort study in the ED of an urban hospital in Japan. The collected data included patient demographics, such as age, sex, and body mass index, presence of one or more factors of modified LEMON criteria for predicting difficult intubation, reasons for intubation, blood gas levels, airway equipment, intubation by emergency physician or not, and the use of the rapid sequence intubation technique. Those with any of the following were excluded from the analysis: (1) no blood gas drawn before intubation, (2) cardiopulmonary arrest, and (3) under 18 years of age. The primary outcome was the first attempt intubation success rates between a severe acidemic patients (SA) group and a non-severe acidemic patients (NA) group. Logistic regression analysis was used to test the first attempt success rates for intubations between those two groups. Results: Over 5 years, a total of 486 intubations were performed; 105 in the SA group and 381 in the NA group. The univariate analysis showed that the first attempt intubation success rate was lower in the SA group than in the NA group (71.4% vs 83.5%, p < 0.01). The multivariate logistic regression analysis identified that severe acidemia was significantly associated with the first attempt intubation failure (OR 1.9, 95% CI 1.03-3.68, p = 0.04). Conclusions: A presence of severe acidemia before endotracheal intubation lowers the first attempt intubation success rate in the ED.

Keywords: acidemia, airway management, endotracheal intubation, first-attempt intubation success rate

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Authors: Suzan Ghaddar, Aline Pinon, Manuel Gallardo-villagran, Mona Diab-assaf, Bruno Therrien, Bertrand Liagre

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Colorectal cancer (CRC) is the third most common cancer and exhibits a consistently rising incidence worldwide. Despite notable advancements in CRC treatment, frequent occurrences of side effects and the development of therapy resistance persistently challenge current approaches. Eventually, innovations in focal therapies remain imperative to enhance the patient’s overall quality of life. Photodynamic therapy (PDT) emerges as a promising treatment modality, clinically used for the treatment of various cancer types. It relies on the use of photosensitive molecules called photosensitizers (PS), which are photoactivated after accumulation in cancer cells, to induce the production of reactive oxygen species (ROS) that cause cancer cell death. Among commonly used metal-based drugs in cancer therapy, ruthenium (Ru) possesses favorable attributes that demonstrate its selectivity towards cancer cells and render it suitable for anti-cancer drug design. In vitro studies using distinct arene-Ru complexes, encapsulating porphin PS, are conducted on human HCT116 and HT-29 colorectal cancer cell lines. These studies encompass the evaluation of the antiproliferative effect, ROS production, apoptosis, cell cycle progression, molecular localization, and protein expression. Preliminary results indicated that these complexes exert significant photocytotoxicity on the studied colorectal cancer cell lines, representing them as promising and potential candidates for anti- cancer agents.

Keywords: colorectal cancer, photodynamic therapy, photosensitizers, arene-ruthenium complexes, apoptosis

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Authors: Byung Keun Yang, Jae Eun Ku, Young Seon Joo, Je Sung You, Sung Phil Chung, Hahn Shick Lee

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The purpose of this study is to review the evidence comparing the efficacy and safety between L-carnitine and extracorporeal elimination therapy in the management of acute valproic acid L-carnitine vs Extracorporeal Elimination for Acute Valproic acid Intoxication. PubMed, Embase, Cochrane library, Web of Science, KoreaMed, KMbase, and KISS were searched, using the terms carnitine and valproic acid. All studies, regardless of design, reporting efficacy or safety endpoints were included. Reference citations from identified publications were reviewed. Both English and Korean languages were included. Two authors extracted primary data elements including poisoning severity, presenting features, clinical management, and outcomes. Thirty two articles including 33 cases were identified. Poisoning severity was classified as 3 mild, 11 moderate, and 19 severe cases. Nine cases were treated with L-carnitine while 24 cases received extracorporeal therapy without L-carnitine. All patients except one expired patient treated with hemodialysis recovered clinically and no adverse effects were noted. A case report comparing two patients who ingested the same amount of valproic acid showed increased ICU stay (3 vs. 11 days) in case of delayed extracorporeal therapy. Published evidence comparing L-carnitine with extracorporeal therapy is limited. Based on the available evidence, it is reasonable to consider L-carnitine for patients with acute valproic acid overdose. In case of severe poisoning, extracorporeal therapy would also be considered in the early phase of treatment.

Keywords: carnitine, overdose, poisoning, renal dialysis, valproic acid

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Authors: Suaka Yaro

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This article provides an alternative examination of the causes and the ramifications of the Ivorian political conflict from 2002 to 2009. The researcher employed a constructivist epistemology and qualitative study based upon fieldwork in different African cities interviewing Ivorians outside and within Ivory Coast. A purposive sampling of fourteen participants was selected. A purposive sampling was used to select fourteen respondents. The respondents were selected based on their involvement in Ivorian conflict. Their experiences on the causes and effects of the conflict were tapped for analysis. Qualitative methodology was used for the study. The data collection instruments were semi-structured interview questions, open-ended semi-structured questionnaire, and documentary analysis. The perceptions of these participants on the causes, effects and the possible solution to the endemic conflict in their homeland hold key perspectives that have hitherto been ignored in the whole debate about the Ivorian political conflict and its legacies. Finally, from the synthesized findings of the investigation, the researcher concluded that the analysed data revealed that the causes of the conflict were competition for scarce resources, bad governance, media incitement, xenophobia, incessant political power struggle and the proliferation of small firearms entering the country. The effects experienced during the conflict were the human rights violation, destruction of property including UN premises and displaced people both internally and externally. Some recommendations made include: Efforts should be made by the government to strengthen good relationship among different ethnic groups and help them adapt to new challenges that confront democratic developments in the country. The government should organise the South African style of Truth and Reconciliation Commission to revisit the horrors of the past in order to heal wounds and prevent future occurrence of the conflict. Employment opportunities and other income generating ventures for Ivorian should be created by the government by attracting local and foreign investors. The numerous rebels should be given special skills training in other for them to be able to live among the communities in Ivory Coast. Government of national unity should be encouraged in situation like this.

Keywords: displaced, federalism, pluralism, identity politics, grievance, eligibility, greed

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Authors: Samir Malhotra, Rajan K. Khandotra, Rakesh K. Dhiman, Neelam Chadha

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There is paucity of data about safety and efficacy of probiotic treatment on patient outcomes in cirrhosis. Specifically, it is important to know whether probiotics can improve mortality, hepatic encephalopathy (HE), number of hospitalizations, ammonia levels, quality of life, and adverse events. Probiotics may improve outcomes in patients with acute or chronic HE. However, it is also important to know whether probiotics can prevent development of HE, even in situations where patients do not have acute HE at the time of administration. It is also important to know if probiotics are useful as primary prophylaxis of HE. We aimed to conduct an updated systematic review and meta-analysis to evaluate the safety and efficacy of probiotics in patients with cirrhosis. We searched PubMed, Cochrane library, Embase, Scopus, SCI, Google Scholar, conference proceedings, and references of included studies till June 2017 to identify randomised clinical trials comparing probiotics with other treatments in cirrhotics. Data was analyzed using MedCalc. Probiotics had no effect on mortality but significantly reduced HE (14 trials, 1073 patients, OR 0.371; 95% CI 0.282 to 0.489). There was not enough data to conduct a meta-analysis on outcomes like hospitalizations and quality of life. The effect on plasma ammonia levels was not significant (SMD -0.429; 95%CI -1.034 – 0.177). There was no difference in adverse events. To conclude, although the included studies had a high risk of bias, the available evidence does suggest a beneficial effect on HE. Larger studies with longer periods of follow-up are needed to determine if probiotics can reduce all-cause mortality.

Keywords: cirrhosis, hepatic encephalopathy, meta-analysis, probiotic

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Authors: L. Lamola, E. Manolas, A. Krause

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Background: The incidence of childhood cancer incidence is increasing gradually in low-middle income countries, such as South Africa. Globally, there is an extensive range of familial- and hereditary-cancer syndromes, where underlying germline variants increase the likelihood of developing cancer in childhood. Next-Generation Sequencing (NGS) technologies have been key in determining the occurrence and genetic contribution of germline variants to paediatric cancer development. We aimed to design and evaluate a candidate gene panel specific to inherited cancer-predisposing genes to provide a comprehensive insight into the contribution of germline variants to childhood cancer. Methods: 32 paediatric patients (aged 0-18 years) diagnosed with a malignant tumour were recruited, and biological samples were obtained. After quality control, DNA was sequenced using an ion Ampliseq 50 candidate gene panel design and Ion Torrent S5 technologies. Sequencing variants were called using Ion Torrent Suite software and were subsequently annotated using Ion Reporter and Ensembl's VEP. High priority variants were manually analysed using tools such as MutationTaster, SIFT-INDEL and VarSome. Putative identified candidates were validated via Sanger Sequencing. Results: The patients studied had a variety of cancers, the most common being nephroblastoma (13), followed by osteosarcoma (4) and astrocytoma (3). We identified 10 pathogenic / likely pathogenic variants in 10 patients, most of which were novel. Conclusions: According to the literature, we expected ~10% of our patient population to harbour pathogenic or likely pathogenic germline variants, however, we reported about 3 times (~30%) more than we expected. Majority of the identified variants are novel; this may be because this is the first study of its kind in an understudied South African population.

Keywords: Africa, genetics, germline-variants, paediatric-cancer

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Authors: Elhussaien Elshiekh

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A study was performed to management and compare radiation doses and image quality during Lumbar spine PA and Lumbar spine LAT, x- ray radiography using Computed Radiography (CR) and Digital Radiography (DR). Standard exposure factors such as kV, mAs and FFD used for imaging the Lumbar spine anthropomorphic phantom obtained from average exposure factors that were used with CR in five radiology centres. Lumbar spine phantom was imaged using CR and DR systems. Entrance surface air kerma (ESAK) was calculated X-ray tube output and patient exposure factor. Images were evaluated using visual grading system based on the European Guidelines on Quality Criteria for diagnostic radiographic images. The ESAK corresponding to each image was measured at the surface of the phantom. Six experienced specialists evaluated hard copies of all the images, the image score (IS) was calculated for each image by finding the average score of the Six evaluators. The IS value also was used to determine whether an image was diagnostically acceptable. The optimum recommended exposure factors founded here for Lumbar spine PA and Lumbar spine LAT, with respectively (80 kVp,25 mAs at 100 cm FFD) and (75 kVp,15 mAs at 100 cm FFD) for CR system, and (80 kVp,15 mAs at100 cm FFD) and (75 kVp,10 mAs at 100 cm FFD) for DR system. For Lumbar spine PA, the lowest ESAK value required to obtain a diagnostically acceptable image were 0.80 mGy for DR and 1.20 mGy for CR systems. Similarly for Lumbar spine LAT projection, the lowest ESAK values to obtain a diagnostically acceptable image were 0.62 mGy for DR and 0.76 mGy for CR systems. At standard kVp and mAs values, the image quality did not vary significantly between the CR and the DR system, but at higher kVp and mAs values, the DR images were found to be of better quality than CR images. In addition, the lower limit of entrance skin dose consistent with diagnostically acceptable DR images was 40% lower than that for CR images.

Keywords: image quality, dosimetry, radiation protection, optimization, digital radiography, computed radiography

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Authors: Terentes Printzios Dimitrios, Loanna Gourgouli, Vlachopoulos Charalambos

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Aims: Atrial fibrillation (AF) remains one of the major causes of stroke, heart failure, sudden death and cardiovascular morbidity. Ablation techniques are becoming more appealing after the latest results of randomized trials showing the overall clinical benefit. On the other hand, imaging techniques and the frontier application of 3D printing are emerging as a valuable ally for cardiac procedures. However, no randomized trial has directly assessed the impact of preprocedural imaging and especially 3D printing guidance for AF ablation. The present study is designed to investigate for the first time the effect of 3D printing of the heart on the safety and effectiveness of the ablation procedure. Methods and design: The 3D-GALA trial is a randomized, open-label, controlled, multicentre clinical trial of 2 parallel groups designed to enroll a total of 100 patients undergoing ablation using cryo-balloon for paroxysmal and persistent AF. Patients will be randomized with a patient allocation ratio of 1: 1 to preprocedural MRI scan of the heart and 3D printing of left atrium and pulmonary veins and cryoablation versus standard cryoablation without imaging. Patients will be followed up to 6 months after the index procedure. The primary outcome measure is the reduction of radiation dose and contrast amount during pulmonary veins isolation. Secondary endpoints will include the percentage of atrial fibrillation relapse at 24h-Holter electrocardiogram monitoring at 6 months after initial treatment. Discussion: To our knowledge, the 3D-GALA trial will be the first study to provide evidence about the clinical impact of preprocedural imaging and 3D printing before cryoablation.

Keywords: atrial fibrillation, cardiac MRI, cryoablation, 3-d printing

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Authors: Kenan Morani, Esra Kaya Ayana

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This study aimed to develop a novel pipeline for COVID-19 detection using a large and rigorously annotated database of computed tomography (CT) images. The pipeline consists of UNet-based segmentation, lung extraction, and a classification part, with the addition of optional slice removal techniques following the segmentation part. In this work, a batch normalization was added to the original UNet model to produce lighter and better localization, which is then utilized to build a full pipeline for COVID-19 diagnosis. To evaluate the effectiveness of the proposed pipeline, various segmentation methods were compared in terms of their performance and complexity. The proposed segmentation method with batch normalization outperformed traditional methods and other alternatives, resulting in a higher dice score on a publicly available dataset. Moreover, at the slice level, the proposed pipeline demonstrated high validation accuracy, indicating the efficiency of predicting 2D slices. At the patient level, the full approach exhibited higher validation accuracy and macro F1 score compared to other alternatives, surpassing the baseline. The classification component of the proposed pipeline utilizes a convolutional neural network (CNN) to make final diagnosis decisions. The COV19-CT-DB dataset, which contains a large number of CT scans with various types of slices and rigorously annotated for COVID-19 detection, was utilized for classification. The proposed pipeline outperformed many other alternatives on the dataset.

Keywords: classification, computed tomography, lung extraction, macro F1 score, UNet segmentation

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Authors: Filipa Vasconcelos

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The administration of endoplasmic reticulum amino peptidases (ERAP1 or ERAP2) inhibitors can be used for therapeutic approaches against cancer and auto-immune diseases. However, one of the main shortcomings of drug delivery systems (DDS) is associated with the drug off-target distribution, which can lead to an increase in its side effects on the patient’s body. To overcome such limitations, the encapsulation of four representative compounds of ERAP inhibitors into Polycaprolactone (PCL), Polyvinyl-alcohol (PVA), crosslinked PVA, and PVA with nanoparticles (liposomes) electrospun fibrous meshes is proposed as a safe and controlled drug release system. The use of electrospun fibrous meshes as a DDS allows efficient solvent evaporation giving limited time to the encapsulated drug to recrystallize, continuous delivery of the drug while the fibers degrade, prevention of initial burst release (sustained release), tunable dosages, and the encapsulation of other agents. This is possible due to the fibers' small diameters and resemblance to the extracellular matrix (confirmed by scanning electron microscopy results), high specific surface area, and good mechanical strength/stability. Furthermore, release studies conducted on PCL, PVA, crosslinked PVA, and PVA with nanoparticles (liposomes) electrospun fibrous meshes with each of the ERAP compounds encapsulated demonstrated that they were capable of releasing >60%, 50%, 40%, and 45% of the total ERAP concentration, respectively. Fibrous meshes with ERAP_E compound encapsulated achieved higher released concentrations (75.65%, 62.41%, 56.05%, and 65.39%, respectively). Toxicity studies of fibrous meshes with encapsulated compounds are currently being accessed in vitro, as well as pharmacokinetics and dynamics studies. The last step includes the implantation of the drug-loaded fibrous meshes in vivo.

Keywords: drug delivery, electrospinning, ERAP inhibitors, liposomes

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Authors: Kimiyo Shimomai, Mihoko Harada

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This study is a literature review of the psychological reactions that occur in end-of-life cancer patients who are nearing death. It searched electronic databases and selected literature related to psychological studies of end-of-life patients. There was no limit on the search period, and the search was conducted until the second week of December 2021. The keywords were specified as “death and dying”, “terminal illness”, “end-of-life”, “palliative care”, “psycho-oncology” and “research”. These literatures referred to Holly (2017): Comprehensive Systematic Review for Advanced Practice Nursing, P268 Figure 10.3 to ensure quality. These literatures were selected with a dissertation score of 4 or 5. The review was conducted in two stages with reference to the procedure of George (2002). First, these references were searched for keywords in the database, and then relevant references were selected from the psychology and nursing studies of end-of-life patients. The number of literatures analyzed was 76 for overseas and 17 for domestic. As for the independent variables, "physical variable" was the most common in 36 literatures (66.7%), followed by "psychological variable" in 35 literatures (64.8%), "spiritual variable" in 21 literatures (38%), and "social variable" in 17 literatures. (31.5%), "Variables related to medical care / treatment" were 16 literatures (29.6%). To summarize the relationship between these independent variables and the dependent variable, when the dependent variable is "psychological variable", the independent variables are "psychological variable", "social variable", and "physical variable". Among the independent variables, the physical variables were the most common. The psychological responses that occur in end-stage cancer patients who are nearing death are mutually influenced by psychological, social, and physical variables. Therefore, it supported the "total pain" advocated by Cicely Saunders.

Keywords: cancer patient, end-of-life, literature review, psychological process

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Authors: Minna K. Miller, Chantel. E. Canessa, Suzanna V. McRae, Susan Shumay, Alissa Collingridge

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Primary care provides the first point of contact and access to health care services. For the pediatric population, the goal is to help healthy children stay healthy and to help those that are sick get better. Primary care facilitates regular well baby/child visits; health promotion and disease prevention; investigation, diagnosis and management of acute and chronic illnesses; health education; both consultation and collaboration with, and referral to other health care professionals. There is a protective association between regular well-child visit care and preventable hospitalization. Further, low adherence to well-child care and poor continuity of care are independently associated with increased risk of hospitalization. With a declining number of family physicians caring for children, and only a portion of pediatricians providing primary care services, it is becoming increasingly difficult for children and their families to access primary care. Nurse practitioners are in a unique position to improve access to primary care and improve health outcomes for children. Limited literature is available on the nurse practitioner role in primary care pediatrics. The purpose of this paper is to describe the development, implementation and evaluation of a Nurse Practitioner-led pediatric primary care clinic in a tertiary care setting. Utilizing the participatory, evidence-based, patient-focused process for advanced practice nursing (PEPPA framework), this paper highlights the results of the initial needs assessment/gap analysis, the new service delivery model, populations served, and outcome measures.

Keywords: access, health outcomes, nurse practitioner, pediatric primary care, PEPPA framework

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Authors: Yasin I. Tayem, Jamil Ahmed, Mahmood Bahzad, Abdullah Alnama, Fahad Al Asfoor, Mahmood A. Jalil, Mohammed Radhi, Ahmed Alenezi, Khalid A. J. Al-Khaja

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Drug-drug interactions (DDIs) represent a significant cause of patient’s morbidity and mortality. The rate of DDIs is rapidly increasing worldwide with the increasing proportion of ageing population and frequent requirement of polypharmacy-prescription of multiple drugs to treat comorbidities. Prescribing physicians are responsible for checking their prescriptions for the presence and severity of DDIs. However, since a large number of new drugs are approved and marketed every year, new interactions between medications are increasingly reported. Consequently, it is no longer practical for physicians to rely only upon their previous knowledge of medicine to avoid potential DDIs. The aim of this study was to explore the perceptions of physicians working at primary healthcare centers in Bahrain towards DDIs and how they manage them during their practice. Methodology: In this cross-sectional study, physicians working at all governmental primary healthcare centers in Bahrain were invited to voluntarily, privately and anonymously respond to a self-administered questionnaire. The questionnaire aims to assess their self-reported knowledge of DDIs and how they check for them in their practice. The participants were requested to provide socio demographic data and information related to their attitudes towards DDIs including strategies they employ for detecting and managing them, and their awareness of drugs which commonly cause DDIs. At the end of the questionnaire, an open-ended item was added to allow participants to further add any comment. Findings and Conclusions: The study is going on currently, and the results and conclusions will be presented at the conference.

Keywords: awareness, drug interactions, health centres, physicians

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Authors: Alisher Ibragimov, Sofya Senotrusova, Aleksandra Beliaeva, Egor Ushakov, Yuri Markin

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Mammography plays a critical role in screening for breast cancer in women, and artificial intelligence has enabled the automatic detection of diseases in medical images. Many of the current techniques used for mammogram analysis focus on a single view (mediolateral or craniocaudal view), while in clinical practice, radiologists consider multiple views of mammograms from both breasts to make a correct decision. Consequently, computer-aided diagnosis (CAD) systems could benefit from incorporating information gathered from multiple views. In this study, the introduce a method based on a Siamese neural network (SNN) model that simultaneously analyzes mammographic images from tri-view: bilateral and ipsilateral. In this way, when a decision is made on a single image of one breast, attention is also paid to two other images – a view of the same breast in a different projection and an image of the other breast as well. Consequently, the algorithm closely mimics the radiologist's practice of paying attention to the entire examination of a patient rather than to a single image. Additionally, to the best of our knowledge, this research represents the first experiments conducted using the recently released Vietnamese dataset of digital mammography (VinDr-Mammo). On an independent test set of images from this dataset, the best model achieved an AUC of 0.87 per image. Therefore, this suggests that there is a valuable automated second opinion in the interpretation of mammograms and breast cancer diagnosis, which in the future may help to alleviate the burden on radiologists and serve as an additional layer of verification.

Keywords: breast cancer, computer-aided diagnosis, deep learning, multi-view mammogram, siamese neural network

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Authors: Nitesh Kumar, Adel Elrasheed, Antonio Gagliardilugo

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Introduction and aims: PRP has been increasing in popularity over the past decade. It is used in many facets of medicine and dentistry such as osteoarthritis, hair loss, skin rejunavation, healing of tendons after injury. Due to the increasing popularity of PRP in third molar surgery in dentistry, this study aims to identify the role of platelet rich plasma and its function in third molar surgery. Methodology: Three databases were chosen to source the articles for review: pubmed, science direct, and Cochrane. The keywords “platelet rich plasma”, “third molar extraction” and “wisdom tooth extraction” and literature review were used to search for relevant articles. Articles that were not in English were omitted and only systematic reviews relevant to the study were collected. All systematic reviews abstracts pertinent to the study were read by two reviewers to avoid bias. Results/statistics: 20 review articles were obtained of which 13 fulfilled the criteria. The Amstar tool validified the strength of these review articles. There is strong evidence in the literature that PRP in third molar surgery decreases post op pain, swelling and recovery time. 20 review articles were obtained of which 13 fulfilled the criteria. The Amstar tool validified the strength of these review articles. There is strong evidence in the literature that PRP in third molar surgery decreases post op pain, swelling and recovery time. Conclusions/clinical relevance: Platelet rich plasma plays a crucial role in patient recovery following the extraction of third molars and should be considered and offered as a routine part of third molar therapy.

Keywords: PRP, third molar, extractions, wisdom teeth

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Authors: Rizwan Iqbal

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Introduction: Re-TURBT has been recommended by international guidelines for patients with non-muscle invasive bladder cancer (NMIBC) who are deemed high-risk. Indications for re-TURBTs remain controversial and studies show mixed outcomes. It should be performed when the initial TURBT specimen lacks detrusor muscle, has tumor stage pT1 or G3/high-grade, or where resection is deemed incomplete. This ensures complete resection of tumors that have a high risk of recurrence as well as accurately identifying any tumors which have been upstaged. The aim of this audit was to evaluate the quality of re-TURBTs in a district general hospital. Method: Data were retrospectively collected from 31 patients who had re-TURBTs between April 2021 and September 2022. Data included baseline demographics, time from initial to re-TURBT, quality of operation note, presence of residual tumor, complications, and administration of chemotherapy within 24 hours of the initial TURBT. Data collection remains ongoing at the time of writing. Results: The mean age was 76 years old and 71.0% of patients were male. 32.3% of patients had their re-TURBT within six weeks and 32.3% had intravesical chemotherapy administered within 24 hours of the initial TURBT. 74.2% of initial TURBTs had detrusor muscle present in the specimen. 48.4% of patients had residual disease following re-TURBT. Just one patient had their pathology upstaged at re-TURBT. The use of the TURBT proforma on the operation note was variable, with 51.6% and 38.7% of surgeons using the proforma after the initial and re-TURBT. Conclusion: Re-TURBT improves bladder cancer staging and is necessary in patients who are deemed high-risk in order to identify any upstaging or recurrence of the disease.

Keywords: urology, bladder cancer, turbt, cancer

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Authors: Melek Göregenli, Işık Gürşimşek

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There has been a great deal of research in the past few decades examining attitudes toward homosexuals.Theoretic research has demonstrated that antihomosexual attitudes are expressed in cognitive, affective, behavioral and cultural components. Homophobia is generally defined as hostility towards or fear of LGBTI people, but can also refer to social and cultural ideologies which stigmatize homosexuality. Negative feelings or attitudes towards non-heterosexual behavior, identity, relationships and community can lead to homophobic behavior and is the root of the discrimination experienced by many lesbian, gay, bisexual and transgender (LGBTI) people. Since the increase in number of hate crimes during the last decade, there has been a sense of urgency to respond to the problem of hate violence in Turkey. The LGBTI Rights Association KAOS-GL indicated that the most of lesbian, gay, bisexual, travesty and transsexuals reported some form of victimization in their lifetimes based on their sexual orientation in Turkey. This study explored the relations between homophobia, right-wing authoritarianism, social dominance orientation and just world belief attitudes towards LGBTI individuals in a sample of 393 Turkish college students from Ege University in Izmir, Turkey. Data were collected with a questionnaire including the Homosexism Scale, the Right-Wing Authoritarianism Scale, Social Dominance Orientation Scale and Just World Belief Scale. Participants completed a questionnaire containing the attitude measures and other several questions related with the socio-demographic variables. Consistent with the previous finding males were more homophobic than females. Contrary to this finding the main effects of other demographic variables (age, income, place of birth, class) were not statistically significant except the department of participants. These findings imply that efforts to garner wide-ranging support for policies designed to change negative attitudes to LGBT people and to enhance the given awareness on homophobia. The results of the study were discussed in cross-cultural and social psychological perspective considering cultural and social values of Turkey and current political circumstances of the country.

Keywords: homophobia, just world belief, right-wing authoritarianism, social dominance orientation, Turkey

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Authors: Syed Asif Hassan, Tabrej Khan, Ibrahim Manssor Al Najar, Mohammed Nasser

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The incredible accomplishment achieved by e-commerce in consumer durable area encouraged us to implement the online e-commerce model to tap the business benefits of electronic pharmacy in Saudi Arabia. The Kingdom of Saudi Arabia is famous for traditional herbal medicine. The rich heritage of traditional medicine has helped the mushrooming of regional pharmaceutical industries manufacturing drugs and other therapeutic against various diseases. However, the implementation of e-commerce in pharmacy has not been employed in the Kingdom of Saudi Arabia. The electronic pharmacy (E-Pharm) is an important sector that is flourishing across the globe and providing benefits of E-Pharm to the customers and suppliers all around the world. In this context, our web-based application of electronic pharmacy is the one of its kind in the Kingdom of Saudi Arabia. Surveys and personal interviews were used to identify key objectives of the proposed web-based portal. As per the findings of the surveys and personal interviews, following key objectives were identified: (a) The online platform will be used for ordering of prescription based medications for consumers. (b) The e-portal will provide space for pharmaceutical retailers who do not have an electronic platform to upload and sell their therapeutic products in an organized way. (c) The web portal will provide a tracking system to track the customer’s behavior like choice, offer, order, shipment, payment, etc. The web-based e-pharmacy portal will be developed using MySQL and PHP. The development of e-pharmacy web portal and e-prescription practices will not only improve the growth of electronic pharmacy but would also decrease the possibility of prescription alteration thus providing safety and improving the quality of service provided to the patient or consumers.

Keywords: e-commerce, E-Pharm, MySQL, PHP

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Authors: Shivani Kuttuva, Bridget Fergie, Andrew Mishreki, Shovkat Mir, Fintan Bergin

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Diaphragm disease (DD) of the small bowel is a condition wherein the bowel lumen is divided into a series of short compartments by multiple circumferential membranes of mucosa and submucosa, leading to pinhole lumen and subsequent obstruction. It is a rare condition commonly attributed to non-steroidal anti-inflammatory drugs (NSAIDs) usage. Herein we present a 31-yr-old-female with a history of NSAIDs usage for one year following neurosurgery, who presented with recurrent idiopathic small bowel obstruction, recalcitrant anaemia, and impaction of capsule endoscope on investigating for anaemia. The capsule endoscopy images demonstrated multiple circumferential strictures with ulcers at its tip and villous atrophy in the proximal bowel, suggestive of NSAIDs related damage. However, due to the lack of awareness of the detrimental effects of NSAIDs on bowel mucosa distal to the duodenum, the underlying aetiology of this clinical presentation remained a mystery for a significant duration. The patient had to undergo repeated laparotomies in order to relieve the symptoms of recurring acute small bowel obstruction. Upon examining the resected specimen under microscopy, the histopathological hallmark of expanded, fibrotic, and congested submucosa was picked up, leading to the confirmation of diaphragm disease. Thus, this case report aims to widen the awareness among clinicians and aid surgeons in devising a management plan for young individuals presenting with recurring episodes of obstruction due to Diaphragm disease.

Keywords: capsule endoscopy, diaphragm disease, NSAIDs, recurrent small bowel obstruction

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Authors: Andriati Nadhilah Widyarini, Ezra Margareth

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Introduction: Rhegmatogenous retinal detachment is a condition where there’s a break in the retina, which allows the vitreous to directly enter the subretinal space. Proliferative vitreoretinopathy (PVR) may develop due to this condition and can result in a new break, which could cause traction on the previously detached retina. Various methods of therapy can be done to treat this complication. Case: This case series involved 2 eyes of 2 patients who had total retinal detachment with advanced PVR. Pars plana vitrectomy was performed, and a 360-degree retinectomy procedure with perfluorocarbon liquid usage was done. This was followed by endo laser retinopexy to surround the border of retinectomy. 5000 cs silicone oil was used in 1 eye, whereas 12% of perfluoropropane gas was used in the other eye as a tamponade. These procedures were performed with meticulous attention to prevent any fluid from entering the subretinal space. Postoperative examination showed attachment of the retina and improvement of the patient’s visual acuity. Both eyes’ intraocular pressure was in the normal range. One eye developed retinal displacement, but no other complications occurred. Discussion: Rhegmatogenous retinal detachment with advanced PVR is a complex situation for vitreoretinal surgeons. PVR is characterized by the growth and migration of preretinal or subretinal membranes. PVR is the most common cause of retinal reattachment failure. A 360-degree retinectomy is an alternative surgical method to overcome this condition. Objectives of this procedure are releasing retinal traction caused by PVR, reducing the recurrence rate of PVR, and reattaching the retina to the pigment epithelial surface. Conclusion: 360-degree retinectomy provides satisfactory retinal reattachment and visual outcome improvement in rhegmatogenous retinal detachment with advanced PVR.

Keywords: RRD, retinectomy, pars plana, advanced PVR

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Authors: Eliane Cristina De Carvalho Mendoza Meza

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The Brazilian Federal Constitution from 1988 innovated with decentralized management, sharing the decision process among the federal government, states, and municipality (federalism). This innovation gave the opportunity to the civil society participates in the public policy agenda, including the municipal one; the state recognized that new actors were needed now it has been one more actor and not the only one. It was in this context that the woman’s Policy Secretaries were created in the three levels of government: federal, state and municipal. It intend to reduce the historical and social differences between men and women, especially in the poorest municipalities, working in a network basis with other secretaries, governmental institutions and non-governmental organizations to promote actions that can result in benefits and empowerment for women. In addition, they promote actions to protect them from domestic violence and to help them to learn how generate income. It was not a calm process, women have been fighting for their rights since the 1970s and despite the gender equality was recognized in the Federal Constitution of 1988, just in 2013 it was possible to see a real growth in the creation of municipal Women’s Policy Secretary. In 2009, just 6.5% of the cities in Brazil had implemented the Secretary; in 2013, it was 11%. The municipality realized that the gender issue was in reality a public problem, so the municipal agenda incorporated it and transformed in public policy, creating the municipal Women’s Policy Secretary. The introduction of a gender policy in Brazilian municipalities shows us that the female citizens are treated as political subjects and it is the first step to try to compensate inequality between men and women in the local level. It becomes more important when the Brazilian federalism is analyzed. In Brazil, the federal government controls the municipalities’ budgets to implement federal public policies and others federal interests, so having a public policy of gender approved by the actors in the local government with so little freedom to manage is something very important. It is necessary mark some points: taking a gender policy to the poorest cities is a form to protect all citizens with no distinction, men and women, as recommended in the Federal Constitution; not all problems in a city center in the municipal agenda, this only happens when a problem is perceived as an issue, it means the women situation was perceived as important, so that it became a public policy; at least, the gender public policy intend to emancipate and contemplate the empowerment of women.

Keywords: federalism, gender, municipal agenda, social participation

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Authors: A. Shirazibeheshti, T. Radwan, A. Ettefaghian, G. Wilson, C. Luca, Farbod Khanizadeh

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Anticholinergic medication has been associated with events such as falls, delirium, and cognitive impairment in older patients. To further assess this, anticholinergic burden scores have been developed to quantify risk. A risk model based on clustering was deployed in a healthcare management system to cluster patients into multiple risk groups according to anticholinergic burden scores of multiple medicines prescribed to patients to facilitate clinical decision-making. To do so, anticholinergic burden scores of drugs were extracted from the literature, which categorizes the risk on a scale of 1 to 3. Given the patients’ prescription data on the healthcare database, a weighted anticholinergic risk score was derived per patient based on the prescription of multiple anticholinergic drugs. This study was conducted on over 300,000 records of patients currently registered with a major regional UK-based healthcare provider. The weighted risk scores were used as inputs to an unsupervised learning algorithm (mean-shift clustering) that groups patients into clusters that represent different levels of anticholinergic risk. To further evaluate the performance of the model, any association between the average risk score within each group and other factors such as socioeconomic status (i.e., Index of Multiple Deprivation) and an index of health and disability were investigated. The clustering identifies a group of 15 patients at the highest risk from multiple anticholinergic medication. Our findings also show that this group of patients is located within more deprived areas of London compared to the population of other risk groups. Furthermore, the prescription of anticholinergic medicines is more skewed to female than male patients, indicating that females are more at risk from this kind of multiple medications. The risk may be monitored and controlled in well artificial intelligence-equipped healthcare management systems.

Keywords: anticholinergic medicines, clustering, deprivation, socioeconomic status

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Authors: Heping Dang, Raymond Yu Wang

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The Langcang-Mekong River is the most important international watercourse in mainland Southeast Asia. In recent years, the six riparian states, China, Myanmar, Laos, Thailand, Cambodia and Vietnam, have confronted increasing disputes over the use of the trans-boundary water. To settle these disputes and protect the fundamental right to water, quite a few inter-state mechanisms have been established, such as the Mekong River Commission, the economic cooperation program of the Greater Mekong Subregion, the ‘Belt and Road Initiative’ and the ‘Lancang-Mekong Cooperation Mechanism’ and the ‘Lower Mekong Initiative’. Non-Governmental Organizations (NGOs) have also been an important and constructive institutional entrepreneur in trans-boundary water governance. Although the status and extent of the right to water are yet to be clearly defined, this paper aims to 1) unpack how the right to water is interpreted and exercised in the Lancang-Mekong River Basin Dispute; and 2) to evaluate the roles of the right to water in settling international water disputes. To achieve these objectives, Secondary data such as archival documents of international law and relevant stakeholders will be compiled for analysis. First-hand information about the organizational structure, accountability, values and strategies of the international mechanisms and NGOs in question will also be collected through fieldwork in the Mekong river basin. Semi-structural interviews, group discussions and participatory observation will be conducted to collect data. The authors have access to the fieldwork because they have abundant experience of collaborating with Mekong-based international NGOs in previous research projects. This research will display how the concepts and principles of international law and the UN guidelines are interpreted in practice. These principles include the definition and extent of the right to water, the practical use of ‘vital human need’, the indicators of ‘adequacy of water’ including ‘availability, quality and accessibility’, and how the right to water is related to the progressive realization of the right to life. This down-to earth research will enrich the theoretical discussion of international law, particularly international human rights law, within the UN framework. Moreover, the outcomes of this research will provide new insights into the roles that the right to water might play in consensus-building and dispute settlement in a rapidly changing context, where water is pivotal for poverty alleviation, biodiversity conservation and the promotion of sustainable livelihoods.

Keywords: international water dispute, Lancang-Mekong River, right to water, state and non-state actors

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Authors: Bheki R. Mngomezulu

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The present paper cogently and systematically traces the history of Umkhonto Wesizwe (MK) and identifies its important role in shaping South Africa’s post-apartheid foreign policy and international relations under black leadership. It provides the political and historical contexts within which we can interpret and better understand South Africa’s controversial ‘Quiet Diplomacy’ approach to Zimbabwe’s endemic political and economic crises, which have dragged for too long. On 16 December 1961, the African National Congress (ANC) officially launched the MK as its military wing. The main aim was to train liberation fighters outside South Africa who would return into the country to topple the apartheid regime. Subsequently, the ANC established links with various countries across Africa and the globe in order to solicit arms, financial resources and military training for its recruits into the MK. Drawing from archival research and empirical data obtained through oral interviews that were conducted with some of the former MK cadres, this paper demonstrates how the ANC forged relations with a number of countries that were like-minded in order to ensure that its dream of removing the apartheid government became a reality. The findings reveal that South Africa’s foreign policy posture and international relations after the demise of apartheid in 1994 built on these relations. As such, even former and current socialist countries that were frowned upon by the Western world became post-apartheid South Africa’s international partners. These include countries such as Cuba and China, among others. Even countries that were not recognized by the Western world as independent states received good reception in post-apartheid South Africa’s foreign policy agenda. One of these countries is Palestine. Within Africa, countries with questionable human rights records such as Nigeria and Zimbabwe were accommodated in South Africa’s foreign policy agenda after 1994. Drawing from this history, the paper concludes that it would be difficult to fully understand and appreciate South Africa’s foreign policy direction and international relations after 1994 without bringing the history and the politics of the MK into the equation. Therefore, the paper proposes that the utilitarian role of history should never be undermined in the analysis of a country’s foreign policy direction and international relations. Umkhonto Wesizwe and South Africa are used as examples to demonstrate how such a link could be drawn through archival and empirical evidence.

Keywords: African National Congress, apartheid, foreign policy, international relations

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Authors: S. Nikpour, S. Vahidi, H. Haghani

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Introduction: Exercise has mental and physical health benefits for patients with advanced stage cancer who actively receive chemotherapy, yet little is known about patients’ levels of interest in becoming more active or their confidence in increasing their activity level. Methods and materials: A convenience sample of 200 patients with advanced-stage cancer who were receiving chemotherapy completed self-report measures assessing physical activity level, mood, and quality-of-life variables. Qualitative data on patient-perceived benefits of, and barriers to, physical activity also were collected, coded by independent raters, and organized by predominant themes. Results: Current physical activity level, physical activity outcome expectations, and positive mood were significantly associated with self-efficacy. Fatigue was the most frequently listed barrier to physical activity; improved physical strength and health were the most commonly listed benefits. Participants identified benefits related to both general health and cancer-symptom management that were related to exercise. 59.5% of participants reported that they were seriously planning to increase or maintain their physical activity level, and over 40% reported having interest in receiving an intervention to become more active. Conclusion: These results suggested that many advanced-stage cancer patients who receive chemotherapy are interested in maintaining or increasing their physical activity level and in receiving professional support for exercise. In addition, these individuals identified general health and cancer-specific benefits of, and barriers to, physical activity. Future research will investigate how these findings may be incorporated into physical activity interventions for advanced-stage oncology patients receiving medical treatment.

Keywords: physical activity, cancer, self-efficacy

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Authors: Mamochana, A. Ramatea, Fumane, P. Khanare

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Enabling the learning environment is a significant and adaptive technique necessary to navigate learners’ educational challenges. However, research has indicated that quality provision of education in the environments that are enabling, especially to learners with visual impairments (LVIs, hereafter) in rural schools, remain an ongoing challenge globally. Hence, LVIs often have a lower level of academic performance as compared to their peers. To balance this gap and fulfill learners'fundamentalhuman rights¬ of receiving an equal quality education, appropriate measures and structures that make enabling learning environment a better place to learn must be better understood. This paper, therefore, intends to find possible means that rural schools of Lesotho can employ to make the learning environment for LVIs enabling. The present study aims to determine suitable assets that can be drawn to make the learning environment for LVIs enabling. The study is also informed by the transformative paradigm and situated within a qualitative research approach. Data were generated through focus group discussions with twelve teachers who were purposefully selected from two rural primary schools in Lesotho. The generated data were then analyzed thematically using Braun and Clarke's six-phase framework. The findings of the study indicated that participating teachers do have an understanding that rural schools boast of assets (existing and hidden) that have a positive influence in responding to the special educational needs of LVIs. However, the participants also admitted that although their schools boast of assets, they still experience limited knowledge about the use of the existing assets and thus, realized a need for improved collaboration, involvement of the existing assets, and enhancement of academic resources to make LVIs’ learning environment enabling. The findings of this study highlight the significance of the effective use of assets. Additionally, coincides with literature that shows recognizing and tapping into the existing assets enable learning for LVIs. In conclusion, the participants in the current study indicated that for LVIs’ learning environment to be enabling, there has to be sufficient use of the existing assets. The researchers, therefore, recommend that the appropriate use of assets is good, but may not be sufficient if the existing assets are not adequately managed. Hence,VILs experience a vicious cycle of vulnerability. It was thus, recommended that adequate use of assets and teachers' engagement as active assets should always be considered to make the learning environment a better place for LVIs to learan in the future

Keywords: assets, enabling learning environment, rural schools, learners with visual impairments

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Authors: Ebtisam A. Benomran, Abdurrauf M. Gusbi, Malak S. Elazarg, M. Sultan, Layla M. Kafu, Arwa M. Matoug, Esra E. Benamara

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Normal pregnancy is associated with metabolic changes leading to decreased insulin sensitivity and reduced glucose tolerance, however, 3-5% of pregnant women proceed to develop gestational diabetes mellitus (GDM). Researcher studied the use of metformin in many fields and the benefit to risk balance of using metformin during pregnancy and the risk of fetotoxic. In this study we examined the use of Metformin to control Glucose in pregnant Women with gestational diabetes mellitus (GDM) and evaluate its safety use during the first trimester of pregnancy.A group of pregnant patients with gestational diabetes mellitus from the first trimester of pregnancy, non smoking with no family history of congenital malformation disease, aged between (20-45 years) and have no liver diseases and who had indicating good compliance at more than one visit over several month until delivery put on Metformin were participated in this trial. Our study shown that all the studied group of pregnant women using metformin 500 mg daily delivered a healthy babies. Meta-analysis by mother risk program showed no increase in incidence of malformations by use Metformin during the first trimester of pregnancy. A hundred outpatients were participated in the survey on the general knowledge and awareness of diabetic patients to their illness and medication used their aged between 20-40 years old. In this survey we realize that 90% of the doctors are not giving the patient full information about their illness and the use of metformin during pregnancy, also about 65% of the patients did not know about the nutritionist in the hospital and the right control diet for diabetes. Courses on first aid, rapid diagnosis of poisoning and follow the written procedures to dealing with such cases.

Keywords: gestational diabetes, malformations, metformin, pregnancy

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