New Emirates Medical Journal - Volume 5, Issue 1, 2024

Addictive learning in the field of medical education refers to the process wherein medical students are highly engaged in the learning process. The aim of the current article is to evaluate the effectiveness of addictive learning strategies, identify barriers, and propose solutions to effectively implement addictive learning in medical education. Addictive learning ensures an increase in the level of student engagement, which in turn determines a better understanding of complex concepts, knowledge retention for longer periods of time, and development of critical thinking and problem-solving skills. Even though addictive learning has been linked with multiple benefits for students, it has its share of challenges, such as a mismatch between engagement and learning objectives, superficial learning, lack of accessibility and inclusivity, questionable long-term effectiveness, concerns about data privacy and security, rising costs, etc., in the educational settings. In conclusion, addictive learning in medical education plays an important role in facilitating learning among medical students. However, this process of planning and implementation of addictive learning in medical education delivery has been linked with multiple concerns. The need of the hour is to adopt a comprehensive package of interventions, such as faculty training or curriculum design, to enable its successful implementation in medical colleges.

Primary Endometrial Squamous Cell Carcinoma (PESCC) is a rare variant of endometrial carcinoma accounting for <1% of all endometrial malignancies. It is a highly aggressive tumor and carries a very poor prognosis with a 5-year survival reaching up to zero. The exact pathogenesis of PESCC is unclear, and different theories have been proposed for its origin. The most widely accepted theory proposes the endometrial squamous metaplasia, progressing to dysplasia and frank squamous cell carcinoma. The role of human papillomavirus infection in its pathogenesis is controversial. The present review aims to brief the clinical features, pathogenesis, diagnosis, and management of PESCC. The literature was searched from March 2003 till April 2024 using different databases like PubMed, SCOPUS, and EMBASE and many English peer-reviewed journals. The following search terms were used: “Primary endometrial squamous cell carcinoma,” “Pathogenesis of PESCC,” “Ichthyosis uteri and PESCC,” and “Management of PESCC.” PESCC is a rare endometrial malignancy, and very few cases have been reported in the literature. The overall prognosis of the disease is poor, and management includes total hysterectomy with lymph node resection followed by chemoradiotherapy, depending on the stage of the malignancy.

Diagnosis and management of pulmonary hypertension (PH) in special populations, including pregnant women, patients requiring intensive care unit admission, and patients who develop complications such as ascites, pericardial effusion or develop COVID-19 infection, are very challenging.

PH is associated with poor outcomes in pregnant women as the haemodynamic changes during pregnancy greatly increase maternal mortality. If PH is suspected in pregnant women, further investigation using transthoracic echocardiography is essential, and confirmation with right heart catheterisation is required. All global guidelines recommend avoidance of pregnancy in patients diagnosed with PAH. However, if the patient becomes pregnant, the risks involved with the continuation of the pregnancy and termination of the pregnancy should be discussed.

Intensive care may be required in patients with PH for the management of comorbid conditions and following major surgeries and irrespective of the underlying cause of PH, haemodynamic compromise in these patients leads to right heart failure. The PH expert centre plays an important role in the critical care management of patients with PH. Patients with PH may also develop complications such as ascites and pericardial effusion; if not rapidly recognised and treated, these complications can lead to poor prognosis in affected patients.

This chapter aims to provide guidance to healthcare professionals in the clinical decision-making process for the diagnosis and management of PH in special populations.

Group 5 pulmonary hypertension (PH) encompasses PH associated with chronic haemolytic diseases, which is the major cause of morbidity and mortality in patients. The prevalence of PH is notably high in sickle cell disease (SCD), thalassemia, hereditary spherocytosis, and paroxysmal nocturnal haemoglobinuria.

Pulmonary symptoms are common with haematological diseases; therefore, systematic evaluation of patients who are at increased risk of developing PH is vital. Evaluation by NT-pro BNP and echocardiography (ECHO) is essential for early referral to PH centres. Right heart catheterisation in patients with haemoglobinopathies is recommended in making a diagnosis of precapillary PH. A V/Q scan should be considered in the evaluation of dyspnoea for detecting thrombotic events in SCD.

Once haemolytic disease is confirmed as the cause of PH, the underlying cause of haemolytic disease is managed with an emphasis on the reversal of hypoxaemia. Evidence suggests that hydroxyurea can treat patients with haemolytic disease and PH, but exchange blood transfusions are used as an alternative when patients are unresponsive to hydroxyurea. Riociguat, a soluble guanylate cyclase stimulator, has been found to be safe and effective in sickle-cell-related pulmonary arterial hypertension. Novel drugs like voxelotor (FDA approved) and crizanlizumab have shown their efficacy in patients with SCD and vaso-occlusive crisis.

Hence, this study emphasises the systematic evaluation of patients for early diagnosis and early positioning of novel agents to prevent PH associated with chronic haemolytic diseases, particularly SCD.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a distinct and treatable form of pulmonary hypertension (PH). It occurs due to persistent thromboembolic obstruction of pulmonary arteries, leading to an increase in pulmonary vascular resistance (PVR) and right ventricular failure. The prognosis of CTEPH patients is poor if left untreated.

The diagnosis of CTEPH is challenging and usually delayed due to non-specific CTEPH symptoms, asymptomatic patients or patient negligence in highlighting specific symptoms, and lack of screening tools. A ventilation/perfusion (V/Q) scan can help detect the early stage of CTEPH, i.e., chronic thromboembolic disease (CTED). Computed tomography (CT) pulmonary angiography is used for determining vascular abnormalities and assessing operability in CTEPH. In the absence of a perfusion defect, haemodynamic measurement while exercising during right heart catheterisation (RHC) serves as an important diagnostic tool in patients with normal haemodynamic at rest.

Once CTEPH is diagnosed, pulmonary endarterectomy (PEA) becomes the treatment of choice in operable cases. If residual pulmonary artery hypertension (PAH) post-PEA occurs, medical therapy with or without percutaneous balloon pulmonary angioplasty (BPA) is given. Anticoagulants (vitamin K antagonists), diuretics, and riociguat (guanylate cyclase–stimulator) are recommended medical therapies for inoperable patients.

It can be concluded that, with the correct diagnostic approach, prevention of misdiagnosis and early detection of CTEPH is possible. Proper diagnosis offers the possibility of a cure for non-operable patients with PEA. The treatment algorithm emphasises the need for a multidisciplinary team with an individualised approach to ensure an optimal treatment response.

Chronic Lung Diseases (CLDs) constitute one of the most frequent causes of pulmonary hypertension (PH) and rank second after PH due to left heart disease. In PH-CLD, destruction of lung parenchyma is associated with decreased functional capacity, diminished quality of life, increased oxygen requirements, and a heightened risk of death.

As both pulmonary arterial hypertension (PAH) and PH due to lung disease are categorized as precapillary PH, it is essential to distinguish between the two conditions, particularly when the lung disease is present with the severe form of PH. If the diagnosis confirms a severe form of PH-CLD, then individualised care is essential in patients with severe lung disease and evidence of right-sided heart failure, particularly those with lower-limb oedema. Moreover, echocardiography (ECHO) and N-terminal-pro hormone B-type natriuretic peptide (NT-proBNP) evaluation are of high importance and must be ordered by the pulmonologist. Right Heart Catheterisation (RHC) is also essential for the determination of the extent and severity of pulmonary vascular involvement. The use of inhaled vasodilators, along with a referral for right heart catheterisation, should be considered at an earlier phase of interstitial lung disease. In addition to therapy, cardiopulmonary rehabilitation programmes have been found to improve six-minute walking tests (6MWT), oxygenation, and functional capacity.

This article discusses the screening of PH-CLD along with the treatment algorithm and suggests the promising role of vasodilators in PH-CLD.

Pulmonary hypertension (PH) due to left heart disease (PH-LHD) is the most common type of PH and is observed in patients with underlying left heart disease conditions, including valvular heart disease, heart failure (HF) with preserved ejection fraction (HFpEF), HF with reduced ejection fraction (HFrEF), cardiomyopathies, and arrhythmic diseases. Group 2 PH is postcapillary PH categorised into 2 components as isolated postcapillary PH (IpcPH) and combined precapillary and postcapillary PH (CpcPH), based on the value of pulmonary vascular resistance (PVR).

PH-LHD diagnosis is a three-step process and includes identification of clinical phenotype, determination of pre-test probability for invasive evaluation, and haemodynamic assessments. Management of PH-LHD primarily encompasses optimisation of treatment of underlying conditions, such as hypertension, obesity and diabetes mellitus, and treatment of PH-LHD with targeted PAH-specific drugs, like phosphodiesterase type 5 inhibitors (PDE5i) and sildenafil. In patients with PH-LHD, the use of PAH-specific drugs can lead to pulmonary oedema and clinical deterioration.

The article aimed to provide updated information on diagnosis and emerging treatment options for PH-LHD. Although the emerging alternative treatment options are not approved, the randomised studies discussed provide insight into the management and thus demand future clinical trials to establish the safety and efficacy of novel molecules and combination therapies.

Pulmonary arterial hypertension (PAH) is a frequent complication of connective tissue diseases (CTDs), such as systemic sclerosis (SSc), mixed connective tissue disease, systemic lupus erythematosus (SLE), and, to a lesser extent, dermatomyositis, rheumatoid arthritis, and Sjögren syndrome. Connective tissue disease-associated PAH (CTD-PAH) is the second most common cause of PAH, following the idiopathic form of PAH. Nearly 15%–30% of patients with SSc develop PAH and have a very poor prognosis and survival rates compared to idiopathic PAH. Also, the majority of these patients present with substantial functional impairment and severe hemodynamics at diagnosis. Therefore, an early diagnosis of CTD-PAH through annual systematic screening and appropriate treatment is crucial in order to achieve optimal clinical outcomes and has been strongly recommended with the highest level of evidence in rheumatology, cardiology, and pulmonary guidelines since 2014. Unfortunately, annual screening in at-risk CTD-PAH patients is not being performed in the majority of patients, leading to substantial delays in therapy.

Group 1 pulmonary artery hypertension (PAH) is a debilitating disease characterized by progressively increased pulmonary vascular resistance (PVR) and mean pulmonary arterial pressure (mPAP) due to obstructions in the pulmonary vasculature. Group 1 PAH is further subdivided into idiopathic PAH, PAH associated with congenital heart disease (PAH-CHD), PAH associated with connective tissue disease (CTD-PAH), portopulmonary hypertension (PoPH), and paediatric PAH, out of which the first 3 contribute to substantial disease burden. Evidence from registries suggests that survival rates are better in PAH-CHD, followed by idiopathic PAH and PAH-CTD. The cause of idiopathic PAH is not evident, but one-third of the patients belong to this group. CTD-PAH is the second most common cause of PAH, following idiopathic PAH. In all cases, lung transplantation is generally considered the last option when medical therapies are not working.

The current article discusses the various unmet needs in the UAE, including less effective monotherapy (exception considered in specific subsets of PAH), late referral to the PH expert center, no systemic follow-up (in patients with PAH-CHD), no routine assessment, and underutilization of screening and treatment algorithms.

This article highlights the current approach to classification, screening, diagnosis, and management of each type of Group 1 PAH. This also emphasizes the need for tailored therapy for each patient. Screening and treatment algorithms can help healthcare professionals in the early detection and effective management of PAH, respectively.

Risk stratification in pulmonary arterial hypertension is critical in determining therapeutic strategies for patients. Patients are stratified into low-, intermediate-, and high-risk groups based on determinants of prognosis like clinical assessment, exercise tests, biochemical markers, echocardiography, and haemodynamic tests. The primary objective of treatment is to shift each of the component tests into a low-risk zone either by treatment escalation alone, as in the case of intermediate-risk patients, or by a combination of treatment escalation and repeat evaluation by right heart catheterisation in high-risk patients. Low-risk patients should be clinically assessed at least every 3 months, but follow-up is more frequent for intermediate- and high-risk patients. Apart from improving survival rates, health-related quality of life is also assessed at baseline and follow-up visits, which may predict the prognosis. Additionally, therapeutic drug monitoring is also essential during visits due to the risk of major side effects during treatment initiation or dose escalation. Initial and follow-up risk stratification can prevent delays in the intensification of therapy, but insurance denials act as a barrier to this approach. Therefore, a dedicated insurance team is required for approval of testing and therapies and a fast-track process to communicate with the pulmonary hypertension expert centre. It can be concluded that risk stratification improves the treatment approach and helps make individualised treatment decisions. It also helps healthcare professionals better allocate treatment resources in cases of scarcity.

Diagnosis of pulmonary arterial hypertension (PAH) is generally challenging due to nonspecific symptom presentation and several potential contributing conditions. Timely diagnosis of PAH is very important as the disease is progressive in nature and associated with increased morbidity and mortality. Therefore, the implementation of appropriate strategies that can reduce the delay in diagnosis of PAH, increase awareness among primary healthcare practitioners, and expedite referral to PAH specialists, are very crucial.

Patients with systemic sclerosis, human immunodeficiency virus, heritable disease, portal hypertension, and congenital heart disease are at high-risk of developing PAH. A definitive screening test is recommended for patients with these high-risk conditions to reduce the time to diagnosis. The diagnosis of pulmonary hypertension begins with a clinical suspicion generally based on symptoms, which is followed by physical examination of the patient and evaluation of haemodynamic criteria.

Integration of a high index of clinical suspicion with any expected abnormalities in basic diagnostic tests, substantially increases the likelihood of early diagnosis of PAH. The diagnostic tests required in the clinical assessment of suspected cases of PAH can be broadly categorised as essential diagnostic tests and additional diagnostic tests. The essential tests required in the diagnosis of PAH include electrocardiography, haematological testing, pulmonary function tests, echocardiography, ventilation-perfusion scan of the lungs, computed tomography scan, right heart catheterisation, genetic testing, and advanced imaging testing.

This article is an attempt to provide guidance to healthcare professionals in the clinical decision-making process for the diagnosis of PAH, which would benefit patients as PAH is progressive in nature.

Pulmonary hypertension (PH) is a progressive disease characterized by elevation of pulmonary arterial pressure over 25mmHg. PH has become a global issue associated with substantial morbidity and mortality despite the emergence of several treatment options in the last two decades.

The Emirates Thoracic Society, Emirates Rheumatology Society, and Emirates Cardiac Society took up the task of coming up with regional practical recommendations. The recommendations were formulated based on a careful consideration of scientific and medical knowledge and the evidence available at the time of publication. All endeavors were directed towards making the updated guideline handy for practicing clinicians in the region involved in the management of patients with PH.

This article highlights the updated guidelines in a reader-friendly format and highlights the recent updates made by the 6th World Symposium on Pulmonary Hypertension and the updated ESC ERS 2022 guidelines on PH with regards to classification. Group 1 sub-group has been further classified into “definitive” and “possible” with the inclusion of sub-group “pulmonary arterial hypertension (PAH) long-term responders to calcium channel blockers” and “PAH with overt features of venous/capillaries (pulmonary veno-occlusive disease/ pulmonary capillary haemangiomatosis) involvement”. Group 2.1 was re-named “PH due to heart failure with preserved left ventricular ejection fraction” and Group 2.2 was re-named “PH due to heart failure with reduced left ventricular ejection fraction”. Group 5 has two major updates: (i) removing splenectomy and thyroid disorders, and (ii) the classification of LAM-associated PH together with other parenchymal lung diseases in group 3.

This article highlights the clinical classification updates and the gaps and challenges associated with genetic testing in the region.

It has been estimated that by 2030, the number of patients with diabetes is expected to rise to 552 million. Moreover, an estimated 20 million new cancer cases were reported in 2022, and 64 million people worldwide are currently suffering from heart failure. Recently, there has been an increasing interest regarding the prescription of a drug that was approved for use in May, 2014, which is called empagliflozin. Up to now, limited data is available on the efficacy, safety, and side effects of empagliflozin against a variety of diseases, including diabetes, heart failure, and cancer. Therefore, this study aimed to gather relevant data on empagliflozin by searching electronic databases, such as Web of Science, Scopus, Pubmed, and Cochrane Library, through October 9^th, 2024. One hundred thirty-eight relevant studies, including review articles, clinical trials, and case reports, were assessed. It was found that orally, once daily use of empagliflozin, in addition to the glucose-lowering effect, suppresses inflammation and improves diastolic function. Empagliflozin inhibits breast cancer stemness by inactivating transcription factors and enzyme pyruvate kinase M2 via enhanced miR-128-3p expression. By inhibiting the sodium-glucose cotransporter, the drug has a well-known safety and efficacy in patients with breast cancer, type 1 or 2 diabetes, acute septic renal injury, renal disease, and heart failure. Regarding efficacy, empagliflozin acts as an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, sodium-glucose cotransporter type 2 inhibitor, vascular resistance prevention, and albuminuria-lowering agent. A recently published observational study confirmed the efficacy and safety of empagliflozin in improving kidney function and glycemic profile and reducing cardiovascular events in diabetic patients with advanced chronic kidney disease. In addition, empagliflozin is efficient as a blood pressure-lowering agent in patients with hypertension and those at higher risk of cardiovascular disease. Furthermore, for patients with diabetes and obesity, empagliflozin reduces the progression of kidney disease and improves clinical conditions in those with high blood pressure. It has a beneficial effect on hemoglobin A1c (HbA1c), body weight, glucose variability, and total daily insulin use in people with type 1 diabetes. Itching or redness of the genital area, genital infection, hematuria, difficulty in urination, bladder pain, painful sexual intercourse, peripheral amputations, and Fournier’s gangrene (rarely informed adverse effects) are the most commonly reported side effects. Additionally, pancreatitis, bad odor, and suicide attempts were recorded in some published case reports. Further evidence-based polypharmacological benefits studies' of empagliflozin associated with its nephroprotective, cardioprotective, and glucose-lowering effects and in cancer were reported to be advantageous.

The SARS-CoV-2 virus is the cause of the COVID-19 illness, which has been discovered to have a number of side effects. The purpose of this study is to present the most recent scientific data about oral symptoms of SARS-CoV-2 and the difficulties the dental system faced throughout the pandemic. When COVID-19 is suspected or confirmed, it is advised that patients undergo a routine intraoral examination because oral symptoms occasionally signal a serious illness or even a life-threatening condition. We think it is crucial to have a thorough understanding of all COVID-19 symptoms, including oral lesions, given the current state of the spread of the disease and the unknown future effects of newly developing viral variations. The internet databases of PubMed, Scopus, Embase, Cochrane Central, Web of Science, and Science Direct were investigated to find out how COVID-19 influences oral health. Our suggestions were based on the most recent recommendations from the American Dental Association, WHO, and the Centers for Disease Control and Prevention's Infection Control Practices for Dentistry. The objectives of this review were to analyze current infection control recommendations and shed light on the oral effects of COVID-19 using the evidence that is currently available. With the present understanding of the pathophysiology and biological behavior of COVID-19, the main question addressed in this review was whether it is reasonable to believe that oral symptoms are a direct result of SARS-CoV-2 infection. In this review, we will look at the possible oral and dental consequences of COVID-19 based on the information that is currently available.