Prince Mohammed bin Abdulaziz Hospital

Importance Potentially inappropriate medications are commonly overprescribed to older adults. Although electronic health record (EHR)-based tools can increase use of evidence-based medications, their ability to reduce prescription of potentially inappropriate medications remains unclear.Objective To test the effects of 2 EHR interventions, designed using behavioral science techniques, on the deprescribing of potentially inappropriate medications compared with usual care in older patients.Design, Setting, And Participants In this 3-group parallel randomized clinical trial, 201 primary care physicians (PCPs) in an academic center in Massachusetts were cluster-randomized in November 2022. Follow-up ended March 15, 2024. The intervention focused on patients of randomized PCPs who were 65 years or older, had a PCP visit between November 10, 2022, and March 15, 2024, and were prescribed at least 90 pills of benzodiazepines, nonbenzodiazepine sedative hypnotics, or at least 2 anticholinergic medications in the past 180 days.Interventions PCPs were randomized to usual care (no intervention) or to 1 of 2 sequential EHR interventions: a precommitment intervention, in which an EHR message was sent to the physician during the first patient visit asking the PCP to initiate deprescribing discussions with a second reminder EHR message at the patient's second visit encouraging deprescribing; and a boostering intervention, in which PCPs received a notification encouraging deprescribing at the first patient visit and an in-basket reminder 4 weeks later.Main Outcomes And Measures The primary outcome was deprescribing at least 1 medication on or after the first patient visit though the end of follow-up. Deprescribing was defined as physician-directed discontinuation or medication tapering assessed at the patient level using EHR data. Generalized estimating equations with a log link and binary-distributed errors were used for analyses, adjusting for clustering and multiple testing using Holm-Bonferroni corrections.Results Of 1146 participants (mean age, 73.6 years [SD, 6.4]; 69.7% female, mean follow-up, 289.9 days), 373 (32.5%) had at least 1 medication deprescribed: 145 (36.8%) in the precommitment group, 122 (34.3%) in the boostering group, and 106 (26.8%) in usual care. Compared with usual care, deprescribing was 40% more likely (relative risk [RR], 1.40; 95% CI, 1.14-1.73; absolute difference, 10.4%) in the precommitment group and 26% more likely (RR, 1.26; 95% CI, 1.01-1.57; absolute difference, 6.5%) in the boostering group. No serious adverse events were reported through the adverse event reporting system. Death rates based on manual chart review were 1.4% in the precommitment group, 3.9% in the boostering group, and 1.8% in the usual care group.Conclusions And Relevance These results support use of EHR tools designed using behavioral science principles to significantly increase rates of deprescribing potentially inappropriate medications used by older adults.Trial Registration ClinicalTrials.gov Identifier: NCT005538065.

Effective analgesia and sedation are critical components of care in adult intensive care units, with strategies ranging from opioid and non-opioid regimens to multimodal and protocol-guided approaches. This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Evidence was synthesized from randomized controlled trials and observational studies across PubMed, Cochrane Library, Scopus, and Web of Science through October 2025, evaluating sedative and analgesic interventions - including opioid, non-opioid, alpha-2 agonist, and protocolized approaches - in adult intensive care unit (ICU) populations. The methodological quality of the chosen studies was assessed using the Modified Downs and Black checklist. A total of 11 eligible studies demonstrated that dexmedetomidine provided comparable or superior sedation quality relative to benzodiazepines and propofol, reduced delirium incidence, and shortened time to extubation; remimazolam yielded equivalent sedation to propofol with fewer hypotensive events; and protocolized or nurse-driven sedation strategies improved ventilator-free days and reduced ICU length of stay compared with daily interruption alone. Multimodal and non-opioid adjuvant therapies reduced opioid requirements and nausea while maintaining hemodynamic stability, and across studies, light, cooperative sedation paired with validated pain and sedation assessment tools was associated with better recovery profiles and fewer cognitive complications. Overall, the evidence supports adopting multimodal, analgesia-first, and non-gamma-aminobutyric-acid (non-GABA) sedation approaches in critical care, with dexmedetomidine and remimazolam offering superior safety and delirium prevention compared with benzodiazepines.

Abstract Background: We introduce an adaptive neural rendering framework that advances dynamic Advanced Life Support (ALS) team training by overcoming limitations of static simulations through continuous volumetric implicit neural representations. Aims and Objectives: The system encodes anatomical structures and physiological dynamics as time-variant neural radiance fields, enabling smooth interpolation and deformation of clinical scenarios during resuscitation. Materials and Methods: A differentiable rendering pipeline synthesises photorealistic medical scenes modulated by latent vectors driven by real-time inputs from wearable sensors and team interventions, capturing disease progression and therapeutic effects. To optimise computational efficiency and maintain real-time performance, the framework employs foveated importance sampling aligned with gaze tracking, concentrating rendering resources on clinically relevant regions. Inverse rendering techniques extract key physiological parameters directly from volumetric neural fields, facilitating seamless integration with clinical assessment dashboards and automated debriefing systems. A distributed synchronisation mechanism ensures multiuser scenario coherence, while federated latent space averaging allows personalised adaptations without compromising global consistency. Interoperability is ensured via resolution-adaptive neural textures and projective augmented reality alignment, enabling integration with existing virtual reality (VR) platforms and traditional mannequin-based workflows. Results: Experimental validation demonstrates enhanced training efficacy through dynamic scenario difficulty modulation and realism adjustment driven by live performance metrics, offering a scalable and adaptive solution for next-generation ALS team education. Conclusion: The ANR framework offers a scalable, adaptive, and realistic approach for next-generation ALS education.

Metabolomics provides powerful means to analyze metabolite profiles in biological samples, enabling insights into biochemical changes under genetic, environmental, or pathological conditions. Nuclear Magnetic Resonance (NMR) spectroscopy is central to metabolomics, but its utility is often constrained by the strong and overlapping resonances of abundant components, such as sugars in plant‑ and food‑derived materials, which obscure signals of lower‑abundance metabolites. Here, we introduce a modified NMR acquisition method that increases sensitivity and specificity by selectively suppressing dominant signals, while enhancing weaker metabolite signals across the spectrum. The method integrates water presaturation with excitation sculpting (ES), yielding a robust 1D presat‑1H‑ES pulse sequence. Validation on a range of sugar-rich samples demonstrated 2–fourfold signal enhancement for low‑abundance metabolites compared with conventional 1H‑ES. Multivariate analyses show the method improves reproducibility and discrimination, enabling detection and comparison of low‑abundance metabolites not accessible with conventional approaches’. Beyond sugar‑rich systems, the method is broadly applicable to other spectral regions where dominant metabolite classes obscure lower‑concentration compounds, including primary metabolites and structurally diverse natural products. Overall, the 1D presat‑1H‑ES significantly enhances resolution and sensitivity of NMR‑based metabolomics, shortens analysis time, and supports more precise profiling for both fundamental studies and translational applications in metabolomics and natural‑products discovery.Graphical Supplementary InformationThe online version contains supplementary material available at 10.1007/s13659-025-00570-3.

Background: Computerized Provider Order Entry (CPOE) systems are critical for medication safety, but their effectiveness relies heavily on the completeness of entered data. Incomplete clinical and anthropometric information can disable Clinical Decision Support Systems (CDSSs), compromising patient safety. Objective: This study aimed to assess the longitudinal evolution of CPOE data completeness, specifically focusing on "Breadth Completeness" (the presence of essential clinical variables), and to identify factors predicting data integrity in a tertiary care setting. Methods: A retrospective cross-sectional study was conducted at a 500-bed tertiary referral center in Riyadh. Data were extracted from the Cerner Millennium CPOE system for three "steady-state" years (2015, 2017, and 2019); years involving major system overhauls (2016 and 2018) were excluded to avoid structural bias. A total of 600 unique patient encounters (200 per year) were selected using systematic random sampling from a chronologically ordered sampling frame to minimize temporal bias. The primary outcome was "Breadth Completeness," defined as the presence of eight key variables: age, gender, marital status, weight, height, diagnosis, vital signs, and allergies. Secondary outcomes included documentation consistency (daily notes). Multivariable logistic regression, adjusted for potential confounders, was used to determine predictors of completeness. Results: The rate of primary data completeness (Breadth) improved significantly over the study period, rising from 5.5% in 2015 to 26% in 2017 and 49.5% in 2019. In the multivariable analysis, the year of documentation (OR = 17.47 for 2019 vs. 2015, p < 0.0001) and length of hospitalization (OR = 1.04, p = 0.045) were significant predictors of completeness. Pharmacist-led medication reconciliation was associated with a 2.5-fold increase in data completeness in bivariate analysis (p < 0.0001). Conclusions: While system maturity has driven substantial improvements in CPOE documentation, critical gaps persist, particularly in anthropometric data required for safety alerts. The study underscores the necessity of mandating "hard stops" for core variables and formalizing pharmacist involvement in data reconciliation to ensure patient safety.

Background: Flail chest is a severe thoracic injury defined by fractures of multiple ribs in at least two locations, resulting in paradoxical chest wall motion and impaired ventilation. It most commonly arises from high-energy blunt trauma and is frequently associated with pulmonary contusions and multisystem injuries. Aim: This article aims to provide an integrated overview of the etiology, epidemiology, pathophysiology, clinical assessment, radiologic evaluation, and management strategies for flail chest to guide effective multidisciplinary care. Methods: A comprehensive narrative review approach was used, synthesizing current trauma guidelines and contemporary evidence on diagnosis, imaging, respiratory support, analgesia, and surgical stabilization of rib fractures (SSRF). Results: Findings indicate that flail chest significantly compromises respiratory mechanics, increases the risk of hypoxemia and pneumonia, and often necessitates hospitalization or mechanical ventilation. CT imaging provides the most accurate diagnosis. Optimal outcomes rely on multimodal analgesia, respiratory support, pulmonary hygiene, and selective early SSRF, which reduces ventilation duration, pneumonia rates, and hospital stay. Conclusion: Early recognition and individualized, multidisciplinary management substantially improve outcomes. Surgical stabilization is particularly beneficial in severe cases with persistent instability or ventilatory dependence.

Background: Hypocarbia—reduced blood CO₂ content, often manifesting as hypocapnia (PaCO₂ &lt;35 mm Hg)—is tightly linked to respiratory alkalosis and broad systemic effects on cerebrovascular tone, myocardial excitability, and oxygen delivery. It arises from an imbalance between metabolic CO₂ production and alveolar elimination, most commonly due to hyperventilation. Aim: To synthesize multidisciplinary perspectives—respiratory care, pharmacologic management, and nursing interventions—on the etiology, evaluation, and treatment of hypocarbia across clinical settings. Methods: Narrative integration of physiologic principles (Henderson–Hasselbalch), epidemiologic patterns in critical care, clinical presentation, diagnostic algorithms (ABG, electrolytes, imaging), and condition‑specific management (ventilator strategies, antimicrobials, anticoagulation, anxiolytics, behavioral therapy). Results: Hypocarbia is prevalent in ICU populations and frequently secondary to hypoxemia, sepsis, pulmonary embolism, asthma/COPD exacerbations, psychogenic hyperventilation, endocrine/toxic triggers, or iatrogenic ventilator settings. Consequences include cerebral vasoconstriction, arrhythmias, and altered oxygen delivery; prognosis hinges on the underlying disease rather than PaCO₂ alone. Team‑based care with standardized monitoring (ABG trends, oxygenation, ventilator reassessment) and targeted therapy improves safety and outcomes. Conclusion: Effective management prioritizes correction of precipitating causes, avoidance of excessive CO₂ clearance (especially on mechanical ventilation), and patient education to prevent recurrence.

Background: Craniotomy is a cornerstone neurosurgical procedure that provides direct access to intracranial structures for treating tumors, vascular lesions, trauma, and infections. Despite technological advances, it remains a high-risk intervention requiring meticulous planning and multidisciplinary coordination. Aim: To review craniotomy in nursing practice, emphasizing perioperative care, neurologic monitoring, and patient safety. Methods: This narrative review synthesizes historical evolution, anatomical considerations, indications, contraindications, equipment, personnel roles, preparation, surgical technique, complications, and postoperative management. Sources include contemporary neurosurgical literature and evidence-based nursing guidelines. Results: Craniotomy techniques have evolved from ancient trephination to modern neuronavigation-assisted approaches. Indications span trauma, neoplasms, vascular disorders, and functional neurosurgery. Contraindications are rare but include severe systemic instability and coagulopathy. Nursing interventions are critical across all phases: preoperative optimization, intraoperative sterility and monitoring, and postoperative surveillance for complications such as hemorrhage, infection, and electrolyte imbalance. Enhanced Recovery After Surgery (ERAS) principles and interprofessional collaboration improve outcomes. Conclusion: Craniotomy remains indispensable for managing complex intracranial pathology. Success depends on anatomical precision, technological integration, and coordinated perioperative care. Nursing professionals play a pivotal role in ensuring safety, reducing complications, and supporting recovery through structured protocols and interdisciplinary teamwork.