Obesity is highly prevalent and disabling, especially in individuals with severe mental illness including bipolar disorders (BD). The brain is a target organ for both obesity and BD. Yet, we do not understand how cortical brain alterations in BD and obesity interact.We obtained body mass index (BMI) and MRI-derived regional cortical thickness, surface area from 1231 BD and 1601 control individuals from 13 countries within the ENIGMA-BD Working Group. We jointly modeled the statistical effects of BD and BMI on brain structure using mixed effects and tested for interaction and mediation. We also investigated the impact of medications on the BMI-related associations.BMI and BD additively impacted the structure of many of the same brain regions. Both BMI and BD were negatively associated with cortical thickness, but not surface area. In most regions the number of jointly used psychiatric medication classes remained associated with lower cortical thickness when controlling for BMI. In a single region, fusiform gyrus, about a third of the negative association between number of jointly used psychiatric medications and cortical thickness was mediated by association between the number of medications and higher BMI.We confirmed consistent associations between higher BMI and lower cortical thickness, but not surface area, across the cerebral mantle, in regions which were also associated with BD. Higher BMI in people with BD indicated more pronounced brain alterations. BMI is important for understanding the neuroanatomical changes in BD and the effects of psychiatric medications on the brain. Obesity is the fifth leading cause of death globally and is one of the leading causes of disability  and highly selected groups , while no significant association was seen in those with BD . There was no interaction between BMI and sex for any of the regions or any of the measures. The full list of interactions is shown in online Supplementary Table S9.BMI and group significantly interacted in lateral occipital cortical thickness , with control participants showing a significant negative association between BMI and cortical thickness , but not with Li treatment .In individuals with BD, higher BMI was associated with greater number of jointly used medication classes  per participant , with progressively steeper associations between BMI and thickness in those with more medications .The number of medication classes was significantly associated with smaller cortical thickness in 22 of 34 regions (64.7%), and in nearly all instances, these associations remained significant when controlling for the effects of BMI (online Supplementary Table S10). Exceptions included the pars opercularis, superior temporal gyrus, and supramarginal gyrus. There was a significant interaction between BMI and the number of medication classes in the isthmus cingulate [There was an interaction between current Li-use and BMI in 13 of the ROIs (38.2%), including caudal and rostral anterior cingulate, medial orbitofrontal gyrus, postcentral gyrus, pars opercularis, pars triangularis, rostral and caudal middle frontal, superior frontal, superior temporal, supramarginal, frontal pole, and insula, such that people who were prescribed Li at the time of scanning showed stronger negative association between BMI and cortical thickness than individuals with BD who were not treated with Li . Amongst the remaining regions, which did not show interaction between BMI and Li, Li was positively associated with cortical thickness even when controlling for the negative effect of BMI in nine regions, including cuneus, precuneus, inferior parietal, lateral occipital, lingual, paracentral, precentral, pericalcarine, and superior parietal gyri.BMI, Li treatment, and the number of medication classes showed negligible multicollinearity (VIF < 1.004). BMI was not significantly associated with illness duration, history of psychotic symptoms, diagnostic subtype, or mood state (online Supplementary Table S11).Z = 3.46, p < 0.001, see Only the fusiform gyrus met the criteria for investigating whether BMI mediates the relationship between the number of medication classes and cortical thickness (online Supplementary Table S10). Specifically, there was a significant indirect effect of the number of medication classes on lower fusiform gyrus thickness through BMI , with 34.6% mediation , all of the regions which were negatively associated with BMI were also negatively associated with the diagnosis of BD. In contrast, only a single ROI (isthmus of the cingulate gyrus) showed association between BMI and surface area, which was positive. Importantly, about a third of the negative association between number of psychiatric medications and cortical thickness in the fusiform gyrus was partially mediated by the association between number of medications and higher BMI. Furthermore, the association between BMI and cortical thickness in isthmus cingulate became steeper with higher number of medication classes used jointly. In contrast, significant negative associations between BMI and cortical thickness in isthmus cingulate and rostral anterior cingulate became non-significant when modelled jointly with a significant positive effect of Li on cortical thickness. There was an interaction between Li and BMI, such that the brain correlates of BMI were more pronounced in individuals with The cortical correlates of obesity in this study closely replicated findings from previous large-scale studies, which also reported negative associations between obesity and cortical thickness or volume, especially in caudal and rostral anterior cingulate, entorhinal cortex, and several frontal lobe regions  allowed us to test for interactions among relevant factors, which could not be conclusively studied in smaller, less powered studies. The multi-site nature of this study, with data from 17 sites in 13 countries, ensured highly generalizable representation of BD from around the world. We focused on overweight/obesity, which is a highly prevalent, but understudied factor in relation to brain structure in BD and which could also provide important insights into negative associations between obesitogenic medications and brain structure. In addition to novel findings on the interplay between BMI, BD, or medications and brain structure, we provide several replications of previous findings of associations between obesity or BD and specific regions of interest.This study has the following limitations. The cross-sectional nature of our study does not allow us to discern the direction of the association, as brain alterations may predate or result from obesity. More detailed markers beyond BMI were not broadly available throughout the ENIGMA-BD Working Group. At the same time, BMI is much easier to acquire and is by far the most frequently used measure (García-García et al., To conclude, we confirmed consistent associations between higher BMI and lower cortical thickness across the cerebral mantle, in regions which were also associated with BD. There were few or no correlates of either condition with cortical surface area. In most regions number of medications remained associated with lower cortical thickness regardless of BMI, but there were also instances of mediation and moderation of associations between number of medication classes and cortical thickness by BMI. In terms of Li treatment, either the positive association between Li and cortical thickness was present regardless of BMI or people treated with Li showed steeper association between BMI and cortical thickness. All in all, BMI is important for understanding the neuroanatomical alterations in BD and the neurostructural correlates of psychiatric medications. We need prospective studies to investigate whether obesity is a modifiable/preventable risk factor for brain alterations in BD and whether the obesity-related negative psychiatric outcomes are related to obesity-related brain alterations.


Pediatric thyroid ultrasound-guided fine-needle aspiration includes the use of dedicated ultrasound guidance algorithms to improve the accuracy and increase the diagnostic yield of the procedure. The refinement of imaging criteria and risk stratification can potentially spare cytological assessment of benign nodules. Molecular testing can also be used to differentiate benign from malignant lesions and to guide their further management. The assistance of artificial intelligence tools will be helpful in this investigation.Thyroid fine-needle aspiration (FNA) is a commonly used diagnostic cytological procedure in pediatric patients for the evaluation of thyroid nodules, triaging them for the detection of thyroid cancer. In recent years, greater attention has been paid to thyroid FNA in this setting, including the use of updated ultrasound score algorithms to improve accuracy and yield, especially considering the theoretically higher risk of malignancy of these lesions compared with the adult population, as well as to minimize patient discomfort. Moreover, molecular genetic testing for thyroid disease is an expanding field of research that could aid in distinguishing benign from cancerous nodules and assist in determining their clinical management. Finally, artificial intelligence tools can help in this task by performing a comprehensive analysis of all the obtained data. These advancements have led to greater reliance on FNA as a first-line diagnostic tool for pediatric thyroid disease. This review article provides an overview of these recent developments and their impact on the diagnosis and management of thyroid nodules in children. In recent years, the overall incidence of thyroid malignancy has increased mainly due to significant improvements in high-resolution ultrasonography (US)-guided fine-needle aspiration (FNA), leading to earlier cancer detection . US is aSubstantial differences in the clinical, pathological and molecular aspects of pediatric thyroid cancers make their preoperative assessment more challenging. From a clinical standpoint, pediatric nodules are relatively less frequent (0.2–5% vs. 20–70%), but they have a greater risk of malignancy  and cancer prevalence (estimated from 1.6-fold to 2.5-fold higher), with the peak of incidence being among 15–19 years old ,12,13,14For these reasons, a more comprehensive understanding of the thyroid cancer background in pediatrics is mandatory to ensure their best management. This review will provide an overview of the current state of the field and the various new methods and technologies that are being used to improve the accuracy of thyroid FNA in this population.We focus on the most recent literature to provide an update on the advancements in the thyroid nodules’ assessment in pediatrics, performing a literature search (date of search: 1 January 2023) in PubMed (Medline) for studies published from 1 January 2020 to 31 December 2022 using the following search terms: “thyroid FNA” and “pediatric(s)” or “children”, requiring the terms “pediatric(s)” or “children” to appear in the title. To further expand the information to articles published before the censoring period, a secondary search of the literature was manually conducted from the references of our primary search, including papers by the application of the same inclusion and exclusion criteria. Articles satisfying the following inclusion criteria were included in our review (regardless of the study design):  study waWorldwide, the most employed ultrasound Thyroid Imaging Reporting and Data Systems (TI-RADS) are the American College of Radiology (ACR) TI-RADS, European Thyroid Association (EU) TI-RADS and American Thyroid Association (ATA) guidelines, with known limits in identifying malignant tumors other than PTC ,15,16,17This differs from what is applied to the adult population by all the systems, with FNA performed only once the nodules are ≥1 cm in size and harbor suspicious US features .In this direction, Dunya et al. investigated 77 pediatric FNA, half of which had suspicious or malignant cytology findings. Using ATA guidelines rather than the ACR TI-RADS system, they observed a better sensitivity but a worse positive predictive value . A slighThe classification of thyroid FNA samples using The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is recommended for children by ATA guidance, which is characterized by more aggressive criteria for FNA than in adults ,23. FurtThe assessment of ROM in a single cytological category and its comparison with its adult counterpart has been extensively explored in recent years, with mixed results. Higher ROM for pediatric patients has been described in the setting of Bethesda classes III, IV and V by Dunya et al., and a study on 340 pediatric FNA confirmed this finding, with greater TBSRTC expected ROM in classes ≥III, suggesting that FNA should be performed for all nodules with ACR TI-RADS score ≥4, independently of their size ,31. SingThyroid molecular genetic testing offers the possibility of obtaining additional information to assist in treatment decisions, particularly for indeterminate nodules at FNA, helping to guide the choice of surgery or observation, even if ATA still does not recommend such analyses on cytological pediatric specimens . To dateIn summary, molecular analysis of thyroid nodules, especially thyroid FNA specimens, is a valuable tool in the management of thyroid lesions, providing important diagnostic and prognostic information that can guide clinical decision-making and improve patient outcomes.Artificial intelligence (AI) may play a significant role in the analysis of ultrasound and other imaging data (radiomics). Indeed, complex algorithms can automate the process of interpreting images, allowing for faster and more accurate diagnoses even in this field, as well as for the prediction of molecular alterations  52]..52].According to a recent meta-analysis, computer-assisted diagnosis has proven to have reliable diagnostic performance, comparable to that of radiologists . A machiIt is important to prioritize the development of treatment guidelines and risk stratification tools to accurately identify pediatric patients who would benefit from surgical intervention. In the future, the potential combination of all clinical, radiological, cytological and molecular data merged with the assistance of artificial intelligence will certainly improve thyroid nodule management and surveillance, and will aid in the understanding of the key biomolecular pathways involved in thyroid oncogenic processes. In this direction, multicentric efforts and collaborations can further help in increasing the number of case series describing uncommon clinical entities and molecular alterations in this group of patients, enhancing our capabilities of developing robust and reliable AI tools for their assessment.


Since the early twentieth century, a number of physicians and professional historians have argued for the integration of the history of medicine into both medical education and clinical practice. After the supplanting of the humoral model of medicine in favor of the germ theory of disease in the late nineteenth century, medical school administrators have repeatedly asked medical historians for their rationale for studying “outdated science” in medical training programs beyond antiquarianism and knowledge for knowledge’s sake. However, a number of arguments can be adduced for the use and relevance of the history of medicine, including the observations that history: 1) provides examples of inspiring or highly ethical individuals who can serve as role models in practitioner identity formation; 2) helps to develop critical analytical skills and other modes of humanistic thought and behavior directly relevant to patient care ; 3) promotes culturally-competent care, since history informs culture; 4) encourages inquiry into the sociocultural factors that affect the development of modern medical ecosystems; 5) provides a philosophical tradition for critiquing ethics in the medical profession. This contribution specifically traces the potential uses of Islamic medical history in the clinic and medical schools in Muslim-majority countries, primarily in the Middle East. This essay provides an overview of the value and practical applications of the history of medicine in Muslim-majority countries in medical education and clinical practice.This contribution is based on my fifteen-year experience teaching medical history, medical ethics, medical sociology, and philosophy at an American medical college in the Middle East (Weill Cornell Medicine – Qatar) at the undergraduate and post-graduate levels. Together with colleagues, I have in addition developed and co-directed 13 ACCME-accredited workshops for clinicians on incorporating humanistic modes of thinking into clinical practice . The ideas below are based on a literature review and my teaching modules, invited lectures, workshops, research, and courses.cross-sectional research such as interventional studies and questionnaires, as well as qualitative observational approaches borrowed from ethnography, anthropology, and sociology have proved illuminating, many aspects of the current practice of medicine and the illness experience cannot be fully understood without a longitudinal examination of prior history: for example, the structure of the profession and its culture, healthcare economics, health delivery systems, beliefs on the origin of disease, health behaviors, and disease models, to cite a few areas.Although Saudi Medical Journal, Heart Views (cardiology), and the Aspetar Sports Journal, devote regular columns to the history of medicine. The International Society for the History of Islamic Medicine, which sponsors an international journal and the biannual International Congress on Islamic Medical History and Ethics, was founded by Dr. Hajar Al Hajar in 2000. The Sultan Qaboos University Medical School in Oman holds an annual medical history essay contest for students each year. In addition, the immensely popular film 1001 Inventions and later accompanying book in 2012 detailing Muslim contributions to science and technology – despite their dubious scholarly quality – have received numerous awards, and have stimulated widespread interest in the history of Islamic science and medicine among educators in the Middle East.History of Medicine During the Islamic Civilization designed to “prove to the students how Islamic faith and teachings stimulated the minds to discover and advance scientific medical knowledge,” and Arab Medical Poetry “to show how poets and poet-physicians have dealt with illness, pain, disability, birth, death and dying.”While research funding for the study of the history of medicine in the Middle East is limited, it is held in high esteem by both Muslim scholars and the general public; many biomedical journals in the region such as the Muqaddimah should be included in history of medicine curricula in medical schools. He coined and explored the concept of ˓asabiyya, or “tribal solidarity,” which is key to understanding the paradoxical historical continuities and modern disjunctions of North African and Islamic cultures.The Tunisian historian Ibn Khaldun (1332-1406 CE) developed a rationalist and proto-scientific historiography that is compatible with modern history of medicine methodologies, and his In other words, Ibn Khaldun was working in the Greek empirical tradition of Aristotle and Hippocrates – he was searching for fundamental axioms of politics, environment, and human behavior to deduce from them general laws of historical development. Ibn Khaldun therefore serves as a valuable paradigm for humanistic and medical educators to illustrate that Islam developed an historical methodology fully compatible with, and drawing on the same intellectual traditions as, modern scientific methods. His observations additionally provide valuable insights into modern Muslim societies, much like westerners today probe Shakespeare to understand human psychology or read Max Weber to illuminate the principles of current social institutions. Excerpts from Ibn Khaldun’s works would be valuable in the syllabus of an introductory cultural competence course in Middle Eastern countries, specifically his comments on the social differences between settled and nomadic cultures, which are still being played out today (sometimes violently) in Egypt, North Africa, the Negev, Jordan, and Kuwait.‘ilm  encompasses all branches of knowledge, both historical and modern, in an analogous way that the forms of the Latin root scio, scire (to know) denoted all areas of human knowledge before Whewell’s narrowing of this semantic field with the neologism “scientist.”al-mantiq and al hisab) and “al-ʿulum al-naqliyya al-wadʿiyya” or “traditionally transmitted sciences” which included theology , law (fiqh), and sayings and traditions of the Prophet (sunnah and hadith).Islam has never endorsed a binary “two cultures” split in humanistic and scientific knowledge: the word The Best Accounts of the Classes of Physicians.Islamic historiography of all periods is generally not positivist and does not often subscribe to myths of progress and evolution; thus Islamic histories provide a solid foundation for valorization of past historical knowledge. Knowledge, arguments, and exempla from the past possess high status in Islamic cultures, and Muslims consciously attempt to imitate the Prophet Muhammad (SAW). Medical history formed a part of Islamic golden age science and medical writing, simply because Al-Farabi, Ibn al-Haytham, Ibn Sina, Al-Razi, and Al-Zahrawi were writing within a still living Aristotelian and Galeno-Hippocratic framework of humoralism and the commentaries on those works. The Damascus physician Ibn Abī Uṣaybiʿah wrote a historical biographical dictionary of ancient and medieval Islamic physicians in 1246 CE entitled sunnah, or traditional way of life), thus the past continues to exert a considerable direct moral influence; 3) historical documents such as the Quran and the oral traditions of the ahadith (prophetic sayings) are viewed as eternal (thus the past and present are indistinguishable); 4) some conservative Muslims equate any aspect of modernity with westernization and colonization and pride themselves on the continuity of their traditional culture; 5) Salafist theologians aligned with national governments, for example the Al-Sheikh family in the Kingdom of Saudi Arabia , have co-opted the concept of bid’ah (innovation), which originally meant heresies (new unorthodox religious practices), to condemn any form of modern change or development in order to maintain the political status quo, thus privileging historical patterns of life. Muslims’ strong orientation to the past, in order to preserve cultural and religious continuity in the face of increasing international secularization, provides an entry way to validating the study of history and medical history as relevant topics in medical education and clinical practice.The following factors predispose Muslims to valorize the past: 1) the Abbasid, Umayyad, and Fatimid caliphates and later Ottoman empire circa 800-1400 CE actively promoted science, technology, music, and literature, and material wealth flourished during this “Islamic Golden Age;” 2) the period of the Prophet Mohammed (SAW) and his companions is held up as an example of correct religious praxis , language-based tools , and narrative approaches such as the use of historical exempla, parables, homilies, and proverbs to sharpen ethical inquiry, to provide just a few brief examples.Within the popular paradigm of self-reflective practice, medical students and practitioners of all religious creeds and cultural backgrounds should be aware of their biases, and how they situate themselves culturally and religiously with respect to their patients – this is the essence of culturally competent care. The Muslim majority nations are extremely diverse with respect to history, culture, and language, even though they share a common religion. Core cultural rituals, customs, and world views are remarkedly resilient in Islamic societies, and the anti-westernization and anti-colonial movements that swept the Muslim world in the 1960s and which culminated in the wave of traditionalism and conservatism following the Iranian Revolution in 1979 have reinforced traditional cultural patterns. Therefore, historical reflection will necessarily form a central part of any Muslim healthcare worker’s self-reflective practice, for example, harmonizing traditional Quranic learning and ways of life with the forces of modernity, globalization, and the scientific doctrines such as the theory of evolution that contradict religious narratives.Kitab al-Tawhid (Book of Oneness [of God]). The subtext of Ibn ‘Abd al-Wahhab’s concept of Tawhid was that there is only one interpretation of Islam, leading to a common belief among many adherents that Islam is monolithic. This was recognized as an extremist view even by his eighteenth-century contemporaries, and the resurgence of Ibn ‘Abd al-Wahhab’s works has been linked to modern jihadist ideologies. Due to the socioeconomic, cultural, and religious complexity of the patient populations in Muslim majority nations, therefore, the author advocates the formal teaching in medical schools of Islamic diversity, including the history of the peoples of the pre-Islamic Middle East, and such unpleasant historical topics as Arab colonization of North African and Persian cultures and the East African slave trade. Most of the current ethnic and political conflicts of the Middle East can be understood with just a cursory review of history.One consequence of Saudi Arabia’s international mosque- and madrasah (kuttab)-building soft power diplomacy strategy was the widespread distribution and formal teaching of ultra-conservative and literalist Wahhabist texts such as qiyas, consent of scholars, and public benefit (maslaha); and secondly, the centering of all knowledge in the Quran, with modern knowledge believed to derive analogically, symbolically, or metaphorically from the Quran’s eternal and comprehensive framework. Serious attempts were made in the 1980s and 1990s by such scholars as Seyyed Hossein Nasr and Ismail Al-Faruqi to Islamicize both science and knowledge.A short course in Islamic epistemologies would be another welcome addition to Middle East medical school curricula in which historical and modern modes of Islamic thought could be introduced and compared analytically with the scope, methods, and aims of common medical modes of rational inquiry such as the scientific method, clinical decision-making, and medical ethical reasoning, with an emphasis on using the best epistemological tool in the right cultural and clinical context. Two brief examples of Islamic epistemological processes (ways of knowing) would include: first, the legal reasoning of Shariah law as pertaining to ethics determinations, including djinn, al ayn, or hasad) or biological agents (microbes or germs) to attitudes that disease is the result of internal imbalance . All of these illness beliefs (disease models) originate in deeply held historical modes of thought intimately related to culture, and are often firmly embedded in linguistic metaphors. Patients’ beliefs about illness can affect their acceptance of a treatment plan, their use of alternative medicine, or may even result in avoidance of evidence-based medicine.In multicultural patient populations, patients often hold widely divergent beliefs about why they become sick. Responses range from views that disease is caused by external forces such as supernatural beings  does not distinguish between physiological illness and illness arising from religious disbelief, doubt, and failure to follow Muslim rituals. All foods mentioned in the Quran , for example, talbeenah, olives, pomegranates, figs, dates, honey, are believed by Muslims to be medicinal in nature. Muslims do not automatically seek psychiatric and psychological services when experiencing abnormal behavior due to the general belief that possession by spirits is the cause of mental illness. These persistent illness beliefs obviously affect patients’ relationships with health systems and practitioners in numerous ways.While the majority of Muslims today accept western evidence-based medicine and receive their medical care in hospitals, remnants of earlier medical philosophies remain influential. For example, the still well-regarded Quran, “no affliction comes about but by Allah’s permission” (64:11). The Quran also promises that “so verily, with the hardship, there is relief” (94:5). To counter surrender to illness, Hanbali jurist Ibn Qayyim Al-Jawziyya (1292–1350) in his compilation Prophetic Medicine espoused ijtihad or “struggle” and “effort” to regain wellness.Fatalism and resignation represent the most common Muslim stances toward illness and misfortune due to the dogma that Allah propels all of creation and sanctions all suffering. According to the Another widespread belief in Islam is that suffering during illness is a process of purification, and brings about expiation of sins and benefits in paradise: “No Muslim is afflicted with any harm …but that Allah expiates his sins because of that” . According to Dif,Muslims know that they do not have the power that permits them to master certain circumstances of their existence, in particular that which touches their health….they understand that Allah is the master of everything, of his destiny specifically. Every human being must live by passing many trials, which are however tests imposed by Allah to distinguish the sincere believers from the hypocrites.The belief that one’s being belongs entirely to God is consistent and widespread in Islam and informs key medical ethical concepts related to the sense of autonomy, fatalism, and the strong prohibition against suicide.In summary, the study of the history of medicine introduces the key concept of paradigm shifts and how dominant medical philosophies  have risen and fallen. Through historical appreciation of different philosophies of medicine, practitioners then become more aware of the economic, social, and cultural dimensions of illness. The big-picture thinking involved in tracing historical processes in medical history research thus encourages practitioners to take a wider view of their own practices which takes into account their ethical, practical, social, and economic roles in society. History, as a reflection of culture, also provides insights into the patient perspective on disease and the profession of medicine itself.The works of Vanessa Gamble and Joel Howell provide the most compelling arguments for requiring historical competency in physicians to aid them in delivering culturally sensitive healthcare. Gamble documented fears expressed in the African American popular press in the 1980s and 1990s during the AIDS crisis that medical doctors were either experimenting on Black patients or that the AIDS virus had been purposefully engineered to unleash genocide on Blacks in America.tibb al-nabi or medicine of the Prophet, which comprises health information contained in the Quran, hadith, and sunnah of the Prophet Mohammed (SAW); 3) remnants of Akkadian, Egyptian, and Persian medicine and; 4) remnants of Greek humoralism, Unani Tibb. According to Al-Kindi, as of 2011 traditional medicine is still widely used in Oman despite the widespread availability of modern medicine.Nigella sativa), garlic , and Murrah .Traditional folk medical practice is prevalent throughout the Middle East and North Africa (MENA) region particularly in non-urbanized areas. Traditional practices historically originate from four sources: 1) pre-Islamic oral traditions, “Bedouin medicine;” 2) Thymus vulgaris is an effective and non-toxic mouth and throat antiseptic used for centuries in Arabian medicine (active ingredient thymol). Practitioners must also be informed about the historical dimensions of folk medicines as well and how they have developed, since many of them possess cultural and religious significance. Faith-based therapies such as Quranic recitation can be successfully suggested to patients as adjuvant therapy to modern provenly efficacious interventions. This training helps clinicians negotiate modern allopathic and traditional treatment strategies with patients and families.A historically-informed practitioner would know the origin and makeup of traditional medicines, since some of them are highly toxic or invasive while others are quite effective and can be recommended within the Traditional Medicine/Complimentary and Alternative Medicine (TM/CAM) model of the World Health Organization, especially for low-income patients. For example, the traditional herbal mixture Za’atar containing wasim, kaii), improper alignment of fractures from tajbir (bonesetting), infection or scarring from bloodletting and cupping (hijama), or heavy metal poisoning  arising from such traditional preparations as kohl  and bint al-dhahab . Lead encephalopathy in children has been reported in regions that use bint al-dhahab or kohls on children, and its importation is now banned in many Middle Eastern countries.Effective traditional topical and internal antibiotics, anti-diarrheals, antipyretics, and other agents have been identified through randomized controlled trials (RCTs). However, the medical case study literature of traditional treatments in the MENA region contains numerous reports of eschars from cauterization .djinn (genies).fard) for Muslims to believe in djinn since they are unambiguously described in the Quran, and in most Muslim-majority countries djinn possession is widely believed to be the main cause of mental illness, often cured by exorcism rituals (ruqya).In a cross-sectional study of 2,514 subjects in Qatar in 2010, Bener and Ghulom reported that 43.5% of men and 34.5% of women believed that mental illness was caused by evil spirits, such as djinn: “intense fear…psychological and nervous diseases, insanity, depression, anxiety, tension, epilepsy, Waswaas (whispers from the Shaytaan), personality disorders…hallucinations.”as-sihr (sorcery) or djinn possession.nafs) and spirits (ruh) scattered throughout the Quran. Early Islamic physicians such as Ibn Sina (980–1037) and Al-Razi (854–925) drew heavily on Aristotle to aid them in understanding the soul and ‘Ali ibn al’Abbas al-Majusi  in his Kitab al-Maliki described many neurological diseases such as hemiplegia, amnesia, and epilepsy in a purely clinical fashion. Al-Majusi’s book was widely reprinted in the Latin translation by Constantinus Africanus called the Liber pantegni; thus, the Greek psychological heritage was expanded upon by the clinical observational work of Islamic physicians, who were foundational to early psychological theory in Europe.Ameen lists the following mental conditions caused by Shaytan (Satan) spirits or Clearly, both Western and Islamic psychological theories therefore share some common philosophical roots and a shared textual traditional. This historical fact, when discussed with Muslim patients, may increase acceptance of western psychiatry. The individual practitioner in the Middle East will need to decide how to negotiate the difficult terrain of differing beliefs on disease origins with patients and families, since pharmacological and psychiatric approaches to mental illness developed in Western countries are not acceptable to all Muslim patients who are unfamiliar with modern psychology’s common origins; dismissing outright supernatural origins of mental illness risks offending patients and challenging deeply held belief systems, resulting in non-adherence and non-compliance.fiqh (law), since many laws and regulations governing medical practice today in these countries can be directly traced to late medieval fatawa (opinions) of the recognized schools of law (madhhabs): the four Sunni schools , the two main Shia schools , the Ibadi madhhab (Oman), as well as numerous other historical schools. Rulings of these schools must be interpreted within historical context, since each school deliberates in a different manner, and is dominant in a particular region of the Muslim world, therefore reflecting local customary law (‘urf). In a few countries, shariah law courts constitute the primary legislative system, while in others they rule only on family matters, and in some cases they compete for authority with civil courts. The Hanbali school operates over most of the Arabian peninsula and is aligned with Salafism, thus its rulings are strict and follow textual authority closely. The more liberal Shafi’i school can be found across Africa and Asia, specifically the Horn of Africa and Indonesia, and its rulings are often quite different from other Sunni schools as the local populations there are not Arabs.The emerging discipline of Islamic medical ethics, initiated during the 1980s to the 1990s following medical innovations such as organ transplantation, IVF, and artificial respiration, should be taught in medical schools in all Muslim-majority countries in tandem with a basic historical grounding in Why should these legal technicalities concern the Muslim medical student or practitioner? Although Imams, Muftis, sheikhs and Mullahs are respected and revered for their wisdom, it is not obligatory to follow their counsel, since Sunni Islam has no formal clerical structures nor can any Muslim claim infallibility. Thus individual Muslim practitioners and patients must make their own medical ethical decisions within their particular Islamic religious belief system in novel situations if there are no extant rulings. Who can speak authoritatively on medical ethics in Islam is a contentious and evolving question among schools of fiqh, governments, scientists, and physicians but the debates are clearly anchored in medieval history. Thus, to productively join these debates, students and physicians will need some grounding in the historical context and historical development of Islamic medical ethics.Adab al-Tabib (Ethics of a Physician), a mixture of deontological and virtue ethics.Medical ethics itself can properly be said to have originated in the pre-Islamic Babylonian empire with the Code of Hammurabi (c. 1754 BCE) which describes medical liability of physicians for killing patients. Both the Aristotelian and Hippocratic ethical traditions can be traced within medieval Islam, and the ninth-century author Al-Ruhawi produced a lengthy treatise on ethics entitled ijma’), analogies (qiyas), and then finally invoking the principle of maslaha (public benefit) if necessary.”maslaha is a form of consequentialist thinking most akin to Utilitarianism and is becoming a more widely used deliberative technique in Islamic bioethics as a result of highly novel developments in biomedicine, such as in vitro fertilization and artificial reproductive technologies, stem cells, and robotics which have no analogues in sacred scriptures. Recently, biomedical researchers have been meeting with Muslim jurists at special international congresses to create policies and issue opinions. Thus modern-day Muslims in healthcare professions will need to acquire some basic knowledge of the historical madhhabs and their reasoning processes in order to participate productively in emerging medical ethical debates which affect Muslim patient populations and research subjects.Islamic medical ethics is primarily deontological, stemming from duties outlined in a hierarchy of texts consisting of the Quran , the Sunnah (acts of the Prophet [SAW]), and Ahadith (collected sayings of the Prophet [SAW] attributed to him by other speakers). As I have explained elsewhere, “if these texts cannot provide unequivocal answers, jurists turn to the consent of scholars  or mahram system. Families always expect to be part of the decision-making process of their individual family members, and families commonly ask physicians not to reveal fatal illnesses to a patient, particularly to the very young and very old. According to Al-Bahri, “in certain Middle Eastern, North African and South Asian societies, the family has final authority in [treatment decision-making], as often the patient is inseparably linked to the family as a whole.”Full medical information disclosure has become the norm in western societies due to the emphasis on patient autonomy and the patients’ rights movement. Historically, however, disclosure of information to patients and patient autonomy manifests quite differently in traditional Muslim families who follow the Complications (2002) or Jerome Groopman’s How Doctors Think (2007), are helpful in modelling professional behaviors and ethics for physicians-in-training, and Muslim doctors’ narratives from the late medieval to modern period are equally valuable.Although there is the risk of perpetuating Thomas Carlyle’s “Great Man Theory of History,” a more gender and racially inclusive list of medical and scientific heroes and heroines from the past who embodied both the moral behaviors and high level of technical proficiency encouraged in modern medicine  may prove valuable in inspiring and instructing physicians and students at all stages of their careers.Qanun fi al-Tibb  and claimed to have mastered the medical knowledge of his time by age eighteen. He wrote on all the topics comprising the medieval quadrivium and trivium and once joked “medicine is not one of the difficult sciences, and therefore I excelled in it in a very short time.”Epidemics I, III and On the Surgery, as a timeless model for close clinical observation. He was the first physician to differentiate measles from smallpox, in al-Jadari wa’l-ḥaṣba , through careful observation.Kitab al-Mansuri and Kitāb al-Ḥāwī fī al-ṭibb are based on several recognizable sources , On Smallpox and Measles appears to be largely original, an important and inspirational fact for Muslims since novel scientific knowledge production in Muslim-majority countries today lags well below western countries according to all standard metrics.Shukuk al-jalinus  that physicians should not rely solely on previous authority but rather question everything.Ibn Sina (Avicenna) is known to most Muslim school children: he wrote over one million words on medicine in the In the modern period, woman physician Nawal El-Saadawi has been inspirational to Muslim doctors in the region for decades due to her advocacy for women in medicine, human rights in Islam, and efforts against female genital mutilation. Born in 1931 in rural Egypt, she has written several memoirs, including a 3-volume autobiography and an account of her time in prison. The historical insights from her 65-year career in medicine are particularly valuable since they chronicle dramatic shifts in women’s professional roles in medicine in the Middle East circa 1955 to 2021.Good Medical Practice and Canada’s CanMEDS in most respects except for item number one, “Commitment to Ihsan and adherence to ethical practice” which is described as the “Physician’s pursuit of professional practice should derive from an internal sense of duty to pursue Ihsan, a sense of social responsibility from the belief that he or she is accountable to a higher being.”ihsan means to do beautiful  deeds as if God were watching the believer and the inclusion of this item underscores again how Muslim societies frame all human activity including the profession of medicine within the scope of religious practice. Due to the highly multicultural makeup of the UAE , the new guidelines are problematic for atheists and non-theists.Thus literature on pioneers and exemplary clinicians in Middle Eastern medicine could fill a gap for modelling desired behaviors in medicine where comprehensive physician competency frameworks are currently lacking. For instance, one of the few competency regimes in the Middle East, a medical professionalism framework of nine core domains, was only recently developed in 2016 in the United Arab Emirates (UAE) by consensus of a select group of Muslim medical authorities. Similar official frameworks are exceedingly rare in the Middle East as it is generally assumed that a good Muslim will also be a good and ethical physician. The UAE framework resembles western antecedents such as the UK General Medical Council’s Islam has developed several unique historical models and methods of care that have affected modern institutions in the Middle East and which can be revisited in imaging new ways of services provision. The Bimaristan (Persian: “place of the sick”) provided publicly-funded health services and physicians financed directly by the Caliph often cared for the poor and the incurably insane. Notable was the use of aesthetics to aid in healing ; in other words, Bimaristans provided a pleasant environment including gardens, open courtyards, and fountains which were used for hydrotherapy to calm patients, in addition to music therapy. Also, inspirational Quranic verses involving illness were often inscribed in the stone-work illustrating the belief that the Quran itself and recitation of its text provides healing powers.waqf, or perpetual charitable endowment. This practice not only serves to redistribute wealth and prevent the intergenerational accumulation of resources among Muslim families, but also reminds the community of the duty to provide for the sick according to the fundamental Islamic pillar of Zakat or charity. In conclusion, health policy or service provision change can only occur if one is willing to imagine other ways of doing things, and the past constitutes a reference manual of different institutional structures, care models, and professional behaviors.Many hospitals historically and today throughout the Muslim world are endowed through the system of In 2006, I developed the following activity on medical oaths, which I have presented to clinicians in ACCME training workshops and medical and premedical students in humanities classes to promote reflection on medical ethics and professionalism. The project is generally preceded by a module on Islamic medical ethics and/or the history of Islamic medicine.Adab, and a comparison of the original oath with modern and Islamic versions.Participants first study a packet of historical medical oaths . After one to two-hour lecture sessions which situate each oath historically, participants engage in small group discussion. Since a modified form of the Hippocratic Oath is the most popular oath administered at US medical schools , the majority of one entire session is devoted to Hippocrates, the Hippocratic ethical tradition in the context of Islamic Participants then write their own oath summarizing in bullet point form or aphoristic style their views on the appropriate rules and guidelines of conduct of a healthcare worker . A debriefing and group discussion is then led by the instructor. The activity collates past wisdom on moral behavior in medicine from previous medical oaths, and allows for reflection on the core principles of physician ethical conduct as well as the purposes and practicality of professional oaths.The preceding discussion has hopefully established that history and historical precedent continue as a living tradition in all facets of Islamic life, including medical training and practice. I therefore recommend that medical schools in Muslim-majority nations formally teach Islamic medical history in conjunction with medical ethics and cultural competency, and that universities develop related specialized courses taught by relevant experts on Islamic law, history, ethics, and theology for Continuing Medical Education. Realistically, a three to six month medical school course would integrate the following humanistic topics in the suggested syllabus below:In conclusion, I suggest that healthcare practitioners in Muslim majority countries educate themselves or seek continuing professional development training at a university on the historical dimensions of medicine in the region in order to:trace the history of Muslim thought (philosophy and theology), with special reference to how medical ethics decisions are currently decided in various madhhabs of shariah law to inform their clinical and research practice,gain knowledge of the history of the Islamic caliphates and the cultural diversity of the Middle East arising from indigenous cultures to better empathize and communicate with the range of peoples living in the region ,understand traditional folk medical practices, including religious healing. Physicians will hopefully over time build a detailed knowledge base about toxic ingredients in traditional compounded and herbal medicines, as well as dangerous pharmacological synergies and contraindications. Physicians will also be able to develop strategies to talk to patients about TM/CAM usage, and traditional beliefs that clash with western evidence-based medicine,develop an interest in medical luminaries from the history of Islamic medicine – Avicenna, Albucasis, Rhazes, and others – to inspire them, and their students, patients and colleagues,be open to traditional attitudes towards mental illness as demon possession, and offer resistant patients options for pharmacological interventions, group and expressive therapies, and Cognitive Behavioral Therapy (CBT) as adjuvant therapy to Quranic recitation and rituals and charms instead of dismissing culturally-relevant cures and alienating patients.


Papua New Guinea (PNG) is undergoing an epidemiological transition with increased mortality from NCDs. This study examined NCDs-attributed mortality and associated sociodemographic factors in PNG.Using WHO 2016 instrument, 926 verbal autopsy (VA) interviews were conducted in six major provinces from January 2018 to December 2020. InterVA-5 tool was used to assign causes of death (COD). Multivariable logistic regression analysis was performed to identify sociodemographic factors associated with mortalities from emerging and endemic NCDs.NCDs accounted for 47% of the total deaths, including 20% of deaths attributed to emerging NCDs and 27% of deaths due to endemic NCDs. Leading CODs from emerging NCDs were identified including cardiac diseases, stroke, and diabetes. The risk of dying from emerging NCDs was significantly lower among populations under age 44y compared with population aged 75+y . People living in urban areas were twice likely to die from emerging NCDs than those in rural areas . People in Madang province were 70% less likely to die from emerging NCDs compared to those from East New Britain province . Leading CODs from endemic NCDs included digestive neoplasms, respiratory neoplasms, and other neoplasms. Only children aged 0-4y had significant lower risk of dying from endemic NCDs compared to the population aged 75+y .Public health interventions are urgently needed, prioritizing urban population and those aged over 44y to reduce premature mortality from NCDs. Non-communicable diseases (NCDs) are medical conditions or diseases that are, by definition, non-infectious and non-transmissible between people . NCDs arThere has been a change in the global distribution of the burden of NCDs. Compared to high-income countries, NCDs now disproportionately affect populations in low- and middle-income countries (LMICs) . About 8Papua New Guinea (PNG) has a very young population, with 38.2% of the population under the age of 15 years . The couThis study aimed to identify sociodemographic factors associated with mortality from NCDs among the general population in PNG by analysing the association of sociodemographic characteristics of the deceased and their causes of deaths.Mortality surveillance data were extracted from the Comprehensive Health and Epidemiological Surveillance System (CHESS), which was designed as a population-based longitudinal study, and established by Papua New Guinea Institute of Medical Research (PNGIMR). CHESS covers both urban and rural populations living in eight sentinel surveillance sites in six major provinces of PNG: Central, Eastern Highlands, East Sepik, Madang, East New Britain (ENB) and Port Moresby (POM)—the National Capital District. These provinces represent the four geographical regions of PNG: Highlands, Southern, Momase and Islands. The selection of these sites was based on the previous integrated Health and Demographic Surveillance System (iHDSS), with adjustment for inclusion of new urban sites in consultation with national and local level stakeholders. The urban-rural sites were defined based on the National Statistics Office’s definition applied to the National Census 2010 , 22. TheThe mortality surveillance data were collected using the WHO 2016 verbal autopsy (VA) instrument . The insThe WHO 2016 VA tool has been adapted for suitable use in PNG. Aside from asking standard questions about the signs and symptoms the deceased experienced prior to death, an additional data module on the deceased identification information was included in the questionnaire, including household location (GPS data) and individual background information. This information allow linkages between mortality data and other existing data components available from the CHESS database such as morbidity data and household socioeconomic data, to enhance the scope of data for analysing sociodemographic factors associated with NCDs mortality in PNG . VA inteThe InterVA-5 diagnostic tool was used for cause of death (COD) analysis. This analytical tool is a computer-based programme that can assign 64 specific CODs and categories aligned with the International Classification of Diseases version 10 . The proInfectious diseases ;Emerging NCDs include cardiac diseases (acute and others), stroke, diabetes;Endemic NCDs included neoplasms, chronic obstruct pulmonary disease, asthma, gastrointestinal disorders, renal disorders, mental and nervous system disorders, malnutrition and endocrine disorders (emerging and endemic NCDs correspond to Group II);Injuries and other external causes (corresponding to Group III) .The rationale for grouping NCD-attributed CODs into emerging NCDs and endemic NDCs has been described elsewhere .Sociodemographic analyses were conducted incorporating three steps. First, COD data were linked with household socioeconomic status (SES) data derived from CHESS database for the corresponding period of time. Data on CODs of 689 deceased were successfully linked with household SES data, using the unique household identification codes. No household SES data from East Sepik Province (ESP) were available as the site was only opened in 2019.A new variable for household wealth index was then created for all COD records. Household wealth index was an overall marker of household SES. This variable was constructed based on household socioeconomic variables including housing characteristics, access to water and sanitation, and household assets, using the principal component analysis (PCA) method. Variables on marital status, education, relationship to the household head, employment status, and access to healthcare services were not statistically significant in the PCA models hence they were excluded from the statistical model. Household wealth indices were then divided into five quintiles, representing the poorest, poor, middle, richer and the richest quintile .Finally, multinomial logistic regression (MLR) analyses were conducted to identify sociodemographic factors associated with mortalities from emerging and endemic NCDs. Since social determinants of mortalities from emerging NCDs and endemic NCDs could be different , 18, anaSignificant factors remained in the MLR model, including sex , age at death , urban-rural sector, provinces, and household wealth quintiles, assuming other predictors remained constant. The main effect was selected in these MLR models to produce maximum likelihood estimates of odds ratios (OR) for mortalities attributed to emerging NCDs and endemic NCDs. The statistical likelihood test was selected to calculate 95% confidence intervals (CI) of OR estimates. A p-value of 0.05 was used to determine statistical significance. No correction for multiple testing was applied to the p-values in study. All the p-values, odds ratios and they were directly produced from the MLR models. Data analyses were performed using Statistical Package for Social Science (SPSS) (version 20) see .The CHESS was granted ethics approvals from Instructional Review Board of PNG Institute of Medical Research  and the Medical Research Advisory Committee of Papua New Guinea . These approvals covered all the data components under the CHESS, including the mortality data which were used in this manuscript.VA interviews were conducted with informed consent. Participant information and consent were integrated as part of the VA questionnaire of the WHO 2016 VA tool. They were informed about their right to withdraw from the study at any stage. Informed consent was sought from self-identified close relatives of the deceased. Informed consent was obtained verbally from all respondents preceding the VA interview. The consents were written in the tablets with name of participant, name of witness and date of consent. VA interviews were conducted at the respondent’s home unless otherwise requested, and in the witnesses of other family or community member. All VA interview respondents were matured adults with close family relationship to the deceased. Among the 1021 deaths identified by the data reporters in the communities through household visits, consents were obtained for conducing 1003 VA interviews, resulted in a participation rate of 98%.Among the 1021 deaths in the communities that were identified by the CHESS’s data reporters based in the surveillance sites through household visits, consents were obtained for conducing 1003 VA interviews, resulted in a participation rate of 98%. The flow chart for death identification, selection for interview and data analysis is shown in NCDs accounted for the largest proportion (47%) of the total deaths, including 20% of deaths attributed to emerging NCDs and 27% of deaths due to endemic NCDs. Infectious diseases accounted for the second largest proportion, 34% of the total deaths, followed by injuries and other external CODs (12%). Neonatal deaths and still births accounted for 3% and maternal deaths was 1%. About 3% of the deaths were unable to identify a specific COD.th quintile) had the highest proportion of deaths from emerging NCDs (28%) and people from rich households (4th quintile) had the highest proportion of deaths from endemic NCDs (25%).For endemic NCDs, only children aged from 0–4 years had a significantly lower risk of dying compared with the oldest age group (75+) . The risks of dying from endemic NCDs were not significantly different between sexes, age groups, urban-rural sectors, provinces, and household wealth quintiles.This study is the first to present an overview of the scope and distribution of sociodemographic factors of mortalities attributed to emerging and endemic NCDs at the population level in PNG. The data show that the diversity of NCD mortalities is occurring across sub-populations. Epidemiological shifts were progressing differently between emerging NCDs and endemic NCDs across ages and sexes, urban and rural areas, provinces, and social classes of the population. The data have indicated an overall trend of increased mortalities associated with emerging NCDs in the urban population, who were twice more likely to die from these diseases than those from rural areas. The risk of dying from emerging NCDs was particularly high among those who aged 45 years and above, and resided in Port Moresby, and urbane areas of Central, Eastern Highlands, East Sepik, and East New Britain provinces. By contrast, the association of the endemic NCDs mortality with sociodemographic characteristics of the deceased was unclear, except for children under five years of age, who were less likely to die from these diseases because these chronic conditions often commence in later years of life and last for years before the patients died from it.About 85% of the PNG population reside in rural areas, mostly involving in subsistence-based agriculture , 30. TheUrbanisation appears a major socioeconomic determinant of the mortality transition in PNG, shifting the CODs in the population from infectious diseases towards NCDs. Unlike the urbanisation processes in other LMICs where the epidemiological transition from infectious diseases to NCDs progress slowly over a period of time , this stThe physical and human contrasts, extensive swamps, impenetrable bush-tangled rocky terrain, and high mountains are still effective barriers to human mobility, settlement and communication in PNG . HoweverUrbanization interplays with local contextual factors providing possible explanations for the variation and differences in trends in mortality in PNG. The burden of NCDs is not equally distributed across the provinces. POM had the highest proportion of mortalities from emerging and endemic NCDs, accounting for 60% of the total deaths, followed by Central province (45%). Central Province has experienced a rapid urbanisation in the 2010s with the development of the PNG Natural Liquefied Project. Urban populations have been reportedly moving away from traditional foods, diets, and life-styles . In new Compared to mortality transitions in other countries in the South Pacific Region, the mortality transition in PNG is likely slower. With about 45% of deaths due to emerging and endemic NCDs, our finding is similar to those reported in the recent study in PNG (48.8%), lower than Solomon (70%) , and FijMortality data from VA interviews were used to assign possible CODs, but the information about the deaths of the deceased provided by the relatives could be biased, particularly for those interviews which were conducted two or more years after the date of death . The deaSince CHESS was designed to have a primary health facility included within the catchment areas of each surveillance site, 95% of the surveillance population reported having access to primary healthcare services . About 9The study has provided insights into the current mortality transition in PNG. Urbanisation and local contextual factors could be the key socioeconomic correlates of the mortality transition in PNG. The study found that different sociodemographic factors contributed to the increased mortalities from emerging and endemic NCDs. Different health policies and interventions are needed to target urban and rural populations to change unhealthy life styles to reduce premature mortality from NCDs. The increased risk of dying from emerging NCDs such as cardiovascular diseases, stroke and diabetes mellitus is evident in urban areas. Urban residents are twice more likely to die from these emerging NCDs, particularly among those who are 45 years and older, and from provinces undergoing rapid urbanisation such as Port Moresby and Central province. By contrast, mortality attributed to endemic NCDs such as neoplasms, chronic respiratory diseases and malnutrition are evenly distributed across ages, sexes, urban-rural sectors, provinces and social classes.As urbanisation may continues in PNG in coming years, profound demographic changes including domestic migration will have greater impacts on the health and well-being of the population. Policy level changes are needed to reduce risk factors among the most at risk populations. This study has provided evidence that can be used by PNG Government agencies and the health sector. Health systems are much in need to reform and restructure to effectively respond to new challenges and to meet with the increased demand for healthcare services for NCDs among the population. Equitable access to effective and quality preventive measures and curative services are needed to protect the population from premature deaths from NCDs. NCDs prevention programmes and interventions need to focus on emerging NCDs and target populations in urban areas and in provinces, where urbanisation is occurring at a rapid pace.Socioeconomic development programmes and health interventions are needed to alleviate poor health conditions, change unhealthy lifestyles and eating behaviors, and reduce the social stress of urban living. Social planners, public health experts and stakeholders need to make greater efforts to improve the health and well-being of the population in an equitable, effective and sustainable manner. This calls for more data and analysis of causes of death to assist the PNG Government in developing strategies to effectively address multiple complex public health issues in such critical epidemiological transitional period in PNG.S1 Data(SAV)Click here for additional data file.