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Interest in global health training experiences among trainees from higher income countries has grown. The Working Group on Ethics Guidelines for Global Health Training (WEIGHT) clarified best practices in 2010 based on expert consensus. These guidelines address both balancing priorities in international partnerships and local sustainability concerns related to short-term experiences. However, the guidelines can be difficult to implement in actual practice. Because our organization predated the availability of these consensus guidelines, we reviewed our current set of practices for hosting service–learning programs at our rural Ugandan clinic for adherence to the WEIGHT guidelines. The discrete activities and standardized processes developed over 10 years of hosting experiences were grouped into broader hosting categories, with consensus among the hosting and sending volunteer coordinators of our non-governmental organization partnership. These practices were then mapped to the WEIGHT guidelines. We found our implementation strategies map these guidelines into a clear checklist of actions that can be used by coordinators involved in global health training programs. We include some of the historical reasons that led to our current processes, which may help other partnerships identify similar practice gaps. We anticipate that this action-oriented checklist with historical context will help accomplish the difficult implementation of best practices in global health training collaborations.

The incidence of early seizures (ES) in traumatic brain injury (TBI) ranges between 1 and 7%. However, the incidence of ES after a non-severe TBI (NSTBI) with traumatic hemorrhage (TH) is unknown. Moreover, the data about seizure prophylaxis (SP) in this population remains inconclusive. We aim to determine the incidence of ES in NSTBI and the efficacy of SP. We retrospectively reviewed all adult patients with NSTBI with evidence of a TH on presentation from 2015 to 2018 at Methodist University Hospital in Memphis TN. Patients with history of epilepsy or receiving antiseizure medications (ASM) were excluded. We collected demographic data, the type, severity, and mechanism of injury; the need for neurosurgical intervention (NSI); ES; and SP use. A total of 633 patients met our inclusion criteria; 94.4% had mild TBI; mean age was 70.5 years (SD 16.9); 55.0% were males; and 49.1% had subdural hematoma (SDH). Same level fall was the most common mechanism of injury in 79%. Forty patients (6.3%) had ES. After excluding seizures on presentation, 22 of 310 (7.1%) patients had an ES in the SP group (16 clinical) vs 5 of 310 (1.6%) in the non-prophylaxis group (all clinical) (P = 0.001). Levetiracetam as SP was used in 83.5%. Patients with combined SDH and traumatic subarachnoid hemorrhage or with multicompartment hemorrhage were more likely to have ES than SDH alone (p = 0.02 and 0.001, respectively). NSI was not a predictor for ES in our cohort. The incidence of ES (clinical and electrographic) in NSTBI with TH patients in our cohort is higher than previously reported in those with non-severe TBI. ES were reported more in the SP group, which might indicate a clinical selection bias giving more moderate TBI and multicompartmental hemorrhage patients receiving ASM for SP. However, prospective studies are required to further determine the predictors of ES in non-severe TBI and the effect of ASM for SP on outcomes and reducing ES in NSTBI patients.

Background Recent concerns linked with the application of chemical pesticides and the increasing necessity of low inputs sustainable agriculture have put the use of microbial biocontrol agents and bio-pesticides to the forefront for their application against plant pathogens and insect–pest management. Results This review tended to scrutinize the prospects of microbial biocontrol agents and microbes-based nano-formulations against plant diseases and for pest management with emphasis on bacteria-based nanoparticles, especially derived from Bacillus species. It also tended to discuss the probable mechanism of action and effect on plant growth along with its prospects in a brief manner. Conclusion The use of microbial biocontrol agents offers effective, eco-friendly, and long-lasting management of plant diseases. The employment of nanotechnology in the field of biopesticides has emerged as a promising solution. Nano-biopesticides in the form of biologically derived active pesticides or compounds integrated as nanoparticles and integrated into a suitable polymer have application in insect–pest management.

Pulmonary mucormycosis is an uncommon pulmonary fungal disease, which is commonly seen in immunocompromised individuals. It is caused by fungi of class Zygomycetes. It constitutes the third most common invasive fungal infection following aspergillosis and candidiasis. Risk factors include patients with hematological malignancies, diabetes mellitus, and immunocompromised states. It is difficult to diagnose early due to non-specific clinical presentation and delay in treatment associated with greater mortality. As we know that Tuberculosis and HIV are highly prevalent in country like India. Post pulmonary tuberculosis is emerging as a risk factor for Pulmonary mucormycosis in the developing countries like India. Patients with non-resolving pneumonia are generally misdiagnosed as Pulmonary tuberculosis. The diagnosis of Pulmonary Mucormycosis is based upon demonstration of fungal hyphae in the clinical specimen. We highlight the importance of clinical suspicion in these cases for early diagnosis and early treatment initiation can reverse morbidity and mortality associated with Pulmonary Mucormycosis. We report 2 cases of Pulmonary mucormycosis present in post-pulmonary tuberculosis patients.

As we know that, Asthma and chronic obstructive pulmonary diseases are well characterized diseases, they can co-exist as asthma-COPD overlap (ACO). The co-existence of asthma-chronic obstructive pulmonary disease overlap (ACO) in chronic obstructive pulmonary disease (COPD) patients is often unrecognized. In patients with a primary diagnosis of COPD or Asthma, the identification of ACO has got implication for better prognosis and treatment. Such patients experience frequent exacerbations, poor quality of life, rapid decline in lung function and high mortality than COPD or Asthma alone. Inhalational steroids provide significant alleviation of symptoms in such patients and some studies suggest that the most severe patients may respond to biological agents indicated for severe asthma. Patients who have asthma with a COPD component tend to present with severe hypoxia because of Irreversible/fixed airway obstruction and impairment of the alveolar diffusion capacity by emphysematous changes. In contrast, patients with COPD who have an asthma component not only have exertional dyspnoea but also develop paroxysmal wheezing or dyspnoea at night or in the early morning. The criteria to diagnose asthma-COPD overlap (ACO) include positive bronchodilator response, sputum eosinophilia or previous diagnosis of asthma, high IgE and/or history of atopy. There is scarcity of literature available in country like India. We highlight the importance of identification of Asthma COPD overlap as different phenotype from COPD or asthma alone as it is challenging to diagnose ACO in India. We report 3 cases having both the features of asthma and COPD, later diagnosed with Asthma-COPD overlap.

The mycotoxin patulin is primarily produced as a secondary metabolite by numerous fungal species and predominantly by Aspergillus, Byssochlamys, and Penicillium species. It is generally associated with fungal infected food materials. Penicillium expansum is considered the only fungal species liable for patulin contamination in pome fruits, especially in apples and apple-based products. This toxin in food poses serious health concerns and economic threat, which has aroused the need to adopt effective detection and mitigation strategies. Understanding its origin sources and biosynthetic mechanism stands essential for efficiently designing a management strategy against this fungal contamination. This review aims to present an updated outline of the sources of patulin occurrence in different foods and their biosynthetic mechanisms. It further provides information regarding the detrimental effects of patulin on human and agriculture as well as its effective detection, management, and control strategies.

Objective EMPOwER, a double-blind, randomised, phase 3 study, evaluated the efficacy and safety of erenumab in adults with episodic migraine from Asia, the Middle East, and Latin America. Methods Randomised patients (N = 900) received monthly subcutaneous injections of placebo, erenumab 70 mg, or 140 mg (3:3:2) for 3 months. Primary endpoint was change from baseline in monthly migraine days at Month 3. Other endpoints included achievement of ≥50%, ≥75%, and 100% reduction in monthly migraine days, change in monthly acute migraine-specific medication treatment days, patient-reported outcomes, and safety assessment. Results At baseline, mean (standard deviation) age was 37.5 (9.9) years, 81.9% were women, and monthly migraine days was 8.2 (2.8). At Month 3, change from baseline in monthly migraine days (primary endpoint) was −3.1, −4.2, and −4.8 days for placebo, erenumab 70 mg, and erenumab 140 mg, respectively, with a statistically significant difference for erenumab versus placebo (P = 0.002 [70 mg], P Conclusions This study of erenumab in patients with episodic migraine from Asia, the Middle East, and Latin America met all primary and secondary endpoints. A consistent numerical benefit was observed with erenumab 140 mg versus erenumab 70 mg across all efficacy endpoints. These findings extend evidence of erenumab’s efficacy and safety to patients under-represented in previous trials. ClinicalTrials.gov identifier: NCT03333109

Green nanotechnology has emerged as a sustainable fabrication technology that has offered tremendous frontiers in the field of food science. This review intends to provide a succinct overview of va...

Organizing pneumonia (OP), can be seen in association with lung injury, infection, drug intoxication, and connective tissue diseases. Patients of rheumatoid arthritis (RA) are prone to develop interstitial lung disease (ILD), but the pulmonary involvement usually occurs several years after the joint manifestations. Only in about 10% cases of RA, the initial manifestation of the disease can be in the form of interstitial lung disease. OP as the initial manifestation of RA is extremely uncommon occurrence. Here is presented a case of 52-year-old male who presented with OP as the initial manifestation of RA. On investigation, the RA factor and anti-CCP Antibodies were positive. Based on clinical, radiological and histopathological findings the diagnosis was established.

Objective: To determine the clinical presentation and different treatment modalities of obstructed jaundice at tertiary care Hospital. Study Design: Prospective observational study. Place and Duration: Present study was conducted in the Department of general Surgery of Liaquat University of Medical and Health Sciences, Jamshoro during two years from July 2015 to June 2017. Patients and Methods: Total 50 patients having obstructed jaundice and either gender were evaluated after taking history, clinical examinations including specific investigations like ultrasound of abdomen, liver function test (LFT), magnetic resonance cholangiopancreatography (MRCP), computed tomography (CT) endoscopic retrograde cholangio pancreatography (ERCP), magnetic resonance imaging (MRI), percutaneous transhepatic cholangiography (PTC) biopsy, tumor markers and x- ray chest for diagnosis and prognosis purpose. All the data was recorded via self-made proforma. Results: Out of all cases, 20 patients were in age group of 30 to 45 year, 21 patients were in age group 46 to 64 years and 09 patients were in age group 65 to 80 year. Thirty one patients were presented with intermittent jaundice and pain,14 patients had jaundice, pruritus, pale stool, dark urine and 5 patients were presented with jaundice, pruritus, pale stool with dark urine, pain, anorexia and weight loss. Thirty one patients were diagnosed with benign lesions and 19 patients had malignant lesions. Most of the patients (26.52%) were treated by ERCP, stent. Fifteen underwent open surgery, and 9 were treated by palliative procedure, chemotherapy, radiotherapy and gene therapy. Conclusion: Obstructed jaundice is a critical problem all over the world, in which initially patients present with jaundice, pain, pruritus with pale stool, dark urine and weight loss. Patients can be treated by ERCP, stent. Fifteen patients underwent open surgery and 9 were treated by palliative procedure, chemotherapy, radiotherapy and gene therapy.

Ayurveda has described eight kinds of honey with the different medicinal values that gets change with the passage of time of one year. Pauttika honey is a specific kind of honey among the eight types of honey produced by Pauttika honey bee, which is indicated in the management of diabetes (Prameha), obesity (Sthaulaya), dyslipidemia, etc. To identify and standardize the type of honey and its honey bee on scientific parameters and the characteristics as mentioned in Ayurveda. Honey was procured from the natural honey hive and Standard methods were used forphysico-chemical analysis, sensory evaluation, and color hunter test.Bee identification was done by an expert entomologist. Analysis of honey, showed that procured honey was Pauttika type of honey as described in Ayurveda and bee was identified as Apis dorsata. Researchersalso found some changes in the properties of honey after the one year like in pH, HMF, Color, and Sensory evaluation. The Physico-chemical analysis of honey samples confirmed the good quality of Pauttikahoney produced by Apis dorsata also confirms a new variety of honey as mentioned in Ayurveda.

Enchondroma protuberans (EP) is a rare form of enchondroma which demonstrates exophytic growth outside the margins of the bony cortex. A previously healthy 18-year-old male presented with chronic painless palpable mass of the left third finger. Radiograph showed a well-circumscribed expansile lucent lesion in the middle phalanx of the left third finger. The magnetic resonance imaging confirmed an expansile cortical-based lesion extending through the cortex into the soft tissues, which demonstrated high T2 signal with internal foci with low to intermediate signal suggestive of internal chondroid matrix. The patient underwent surgical excision, curettage and bone grafting, and surgical pathology study confirmed the diagnosis of EP. A rare case of EP involving a phalanx of the hand was described in this study. Imaging, particularly magnetic resonance imaging, plays a key role for accurate preprocedural diagnosis.

BACKGROUND AND PURPOSE We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores

Pyonephrosis is gross accumulation of pus within an obstructed renal collecting system that, if left untreated, can lead to potentially fatal septic shock. Treatment requires urgent decompression coupled with systemic antibiotics. Percutaneous nephrostomy (PCN) placement, first described in 1976 for the treatment of pyonephrosis, is now widely utilized for emergent decompression in these patients. When performed by an experienced interventional radiologist, PCN is a safe procedure with technical success rates of over 96 to 99%. This article will address the clinical presentation of pyonephrosis, and will discuss the indications, technique, complications, and outcomes of emergent PCN placement. Additionally, the expanded indications for PCN placement in nonemergent scenarios will also be described.

Background Rates of burnout among physicians have been high in recent years. The electronic health record (EHR) is implicated as a major cause of burnout. Objective This article aimed to determine the association between physician burnout and timing of EHR use in an academic internal medicine primary care practice. Methods We conducted an observational cohort study using cross-sectional and retrospective data. Participants included primary care physicians in an academic outpatient general internal medicine practice. Burnout was measured with a single-item question via self-reported survey. EHR time was measured using retrospective automated data routinely captured within the institution's EHR. EHR time was separated into four categories: weekday work-hours in-clinic time, weekday work-hours out-of-clinic time, weekday afterhours time, and weekend/holiday after-hours time. Ordinal regression was used to determine the relationship between burnout and EHR time categories. Results EHR use during in-clinic sessions was related to burnout in both bivariate (odds ratio [OR] = 1.04, 95% confidence interval [CI]: 1.01, 1.06; p = 0.007) and adjusted (OR = 1.07, 95% CI: 1.03, 1.1; p = 0.001) analyses. No significant relationships were found between burnout and after-hours EHR use. Conclusion In this small single-institution study, physician burnout was associated with higher levels of in-clinic EHR use but not after-hours EHR use. Improved understanding of the variability of in-clinic EHR use, and the EHR tasks that are particularly burdensome to physicians, could help lead to interventions that better integrate EHR demands with clinical care and potentially reduce burnout. Further studies including more participants from diverse clinical settings are needed to further understand the relationship between burnout and after-hours EHR use.

We describe two siblings with diffuse, mutilating palmo-plantar keratoderma suggestive of Olmsted syndrome, with significantly compromised quality of life in the form of inability to walk and grasp objects. This was accompanied by severe pruritus and erythromelalgia-like symptoms. The keratoderma responded to acitretin therapy but there was paradoxical worsening of burning and pruritus which were further disabling. The poor response to medical and phototherapy in relieving these symptoms is described.

Background: The high incidence, chronicity, frequent recurrences and severity of hand eczema leads to a massive impact on the quality of life. Despite great medical and socioeconomic importance, there is a paucity of data that addresses the cost of illness and economic factors associated with hand eczema. Most of the studies have originated from Europe and none have been reported from India. Aim: To analyze the clinical subtype, the pattern of contact sensitization and the impact of severity of disease on the quality of life and cost of illness in patients of hand eczema. Methods: Hundred patients of hand eczema were recruited and evaluated for morphological patterns of the condition, hand eczema severity index and quality of life (Dermatology Life Quality Index questionnaire). All patients were subjected to patch tests with Indian standard series, cosmetic series and personal or work-related products. The economic burden of hand eczema was measured by both its direct and indirect costs. Results: Morphologically, chronic dry fissured eczema 36 (36%) was the most common pattern followed by mixed type 19 (19%), hyperkeratotic palmar eczema 15 (15%), vesicular eczema with recurrent eruption 9 (9%), nummular eczema 7 (7%) and wear and tear dermatitis 7 (7%). Seventy nine patients gave positive patch test results. Etiological profile of the most common allergens, as established with a patch test, include potassium dichromate 18 (18%) followed by cetrimonium bromide 17 (17%), nickel 16 (16%), gallate 14 (14%), garlic 9 (9%) and patient's own product 8 (8%). Allergic contact dermatitis was the most common clinical pattern of hand eczema seen in 45 (45%) patients, followed by an irritant 14 (14%) and a combination of both 13 (13%). The average total cost of illness was INR 13,783.41 (0–93,000) per individual per year with an average direct cost of INR 2,746.25 ± 1,900 and indirect cost of INR 4911.73 ± 13237.72, along with a positive correlation with the Dermatology Life Quality Index (P = 0.00). The hand eczema severity index was marginally correlated with direct costs (P = 0.07) and highly correlated with indirect costs (P = 0.024). Conclusion: Hand eczema has a huge impact on the quality of life and economic consequences. Limitations: In our study, parameters like Dermatology Life Quality Index and hand eczema severity index could have been affected by the chronicity of disease as being a tertiary referral centre, most of the recruited patients had severe and persistent hand eczema at the time of visit. Also, cost of illness was based on retrospective calculations on recall basis.

Background: Diagnosis of onychomycosis involves direct microscopic examination with potassium hydroxide, culture or histopathology with periodic acid–Schiff staining. Nail dermoscopy (onychoscopy) is a noninvasive, rapid and easily available diagnostic tool though its utility in onychomycosis remains unexplored. Objective: To describe the various onychoscopic patterns and compare its percentage positivity with that of standard potassium hydroxide examination, culture and histopathology in patients with a clinical diagnosis of onychomycosis. Methods: The study recruited 100 patients with a presumptive clinical diagnosis of onychomycosis. A detailed history, physical examination including that of nails and clinical photography was followed by onychoscopy with DermLite DL3. The nail clippings were sent for direct microscopic examination with potassium hydroxide, mycological culture and histopathology with periodic acid–Schiff stain. The patient was said to have onychomycosis if at least one of the three tests was positive. Results: Onychomycosis was confirmed by potassium hydroxide and/or culture and/or histopathology in 88 patients. Onychoscopic features were identified and their association with different clinical variants of onychomycosis was attempted. Percentage positivity for diagnosing onychomycosis in decreasing order was: direct microscopic examination with potassium hydroxide followed by spiked pattern, subungual hyperkeratosis, distal irregular termination on onychoscopy, histopathology, mycological culture and ruins aspect again observed on onychoscopy. Limitations: Small sample size. Conclusions: Many onychoscopic features are highly specific for different variants of onychomycosis so onychoscopy may serve as an important and quick adjunct to diagnose onychomycosis until other time-consuming investigations, such as culture and periodic acid–Schiff become available. Studies on a larger population will help arrive at a logistic conclusion.

Severe acute respiratory distress syndrome coronavirus 2 or CoV2 emerged in 2019 and is responsible for the ongoing worldwide pandemic. There are multiple ongoing vaccine and treatment trials to decrease transmission, confer protection against infection, and improve patient's clinical course including morbidity and mortality. This can only be possible with a detailed understanding of the molecular structure and genomics of this particular virus to better identify possible targets. In this chapter, I have highlighted pertinent details of the viral structure, genetic expression, various immune interactions, and specific host evading viral defenses with emphasis on possible targets for above.

Every anticoagulation decision has in inherent risk of hemorrhage; intracerebral hemorrhage (ICH) is the most devastating hemorrhagic complication. We examined whether combining ischemic and hemorrhagic stroke risk in individual patients might provide a meaningful paradigm for risk stratification. We enrolled consecutive patients with anticoagulation-associated ICH in 15 tertiary centers in the USA, Europe and Asia between 2015 and 2017. Each patient was assigned baseline ischemic stroke and hemorrhage risk based on their CHA2DS2-VASc and HAS-BLED scores. We computed a net risk by subtracting hemorrhagic from ischemic risk. If the sum was positive the patient was assigned a “Favorable” indication for anticoagulation; if negative, “Unfavorable”. We enrolled 357 patients [59% men, median age 76 (68–82) years]. 31% used non-vitamin K antagonist (NOAC). 191 (53.5%) patients had a favorable indication for anticoagulation prior to their ICH; 166 (46.5%) unfavorable. Those with unfavorable indication were younger [72 (66–80) vs 78 (73–84) years, p = 0.001], with lower CHA2DS2-VASc score [3(3–4) vs 5(4–6), p

A wide variety of wires are available for use in interventional radiology, with wires demonstrating differences in construction, diameter, length, coating, shape, and taper. It is crucial to understand the difference in characteristics between these wires to select the most effective and safe wire for the intended purpose when undertaking a procedure. This article reviews the qualities and functions of different types of wires to aid in this decision-making process.

With a goal of improving efficiency and reducing workload outside of visits, we sought to examine a primary care redesign process aimed at reducing refill requests made outside of office visits. Data on the number of refill encounters per panel member were collected at 17 clinics before, during, and after the implementation of a redesign process. There was an initial reduction in the number of medication refill encounters, and the rate of refill encounters continued to decline following implementation. Variation across clinic contexts suggests that redesign processes may need to be tailored for different settings to optimize effectiveness.

Tuberculosis (TB) and sarcoidosis are multisystem, chronic granulomatous diseases. Although characterized by similar clinical manifestations, these disease entities vary significantly in etiologies and management. Sarcoidosis is an immunological disorder of unknown etiology, characterized by the presence of noncaseating granulomas in the tissues involved. TB is the infectious disease caused by Mycobacterium tuberculosis, characterized by granulomas with caseous necrosis. It is rare to have both the diseases concomitantly. We present the case of a 38-year-old male with microbiological confirmation of coexistent pulmonary TB and sarcoidosis.

The whole world is suffering from the severity caused due to the outbreak of novel coronavirus since last year. During this period, the relation of functional foods in combating and reducing the risk of this outbreak came to the light. Functional dairy products are in high demand due to their health-promoting effects and ability to incorporate diverse bioactive ingredients. The different herbs and nutraceuticals contain varieties of bioactive that can be conveyed through food to confer a health benefit to the consumer. Milk serves as the most efficient carrier for these functional ingredients for targeted health benefits. This review tends to explore the potential of various functional dairy foods in combating COVID-19 and its way forward in the market in near future.

ObjectiveTo evaluate individual and group long-term efficacy and safety of erenumab in individuals with episodic migraine (EM) for whom 2–4 prior preventatives had failed.MethodsParticipants completing the 12-week double-blind treatment phase (DBTP) of the LIBERTY study could continue into an open-label extension phase (OLEP) receiving erenumab 140 mg monthly for up to 3 years. Main outcomes assessed at week 112 were: ≥50%, ≥75% and 100% reduction in monthly migraine days (MMD) as group responder rate and individual responder rates, MMD change from baseline, safety and tolerability.ResultsOverall 240/246 (97.6%) entered the OLEP (118 continuing erenumab, 122 switching from placebo). In total 181/240 (75.4%) reached 112 weeks, 24.6% discontinued, mainly due to lack of efficacy (44.0%), participant decision (37.0%) and adverse events (AEs; 12.0%). The ≥50% responder rate was 57.2% (99/173) at 112 weeks. Of ≥50% responders at the end of the DBTP, 36/52 (69.2%) remained responders at ≥50% and 22/52 (42.3%) at >80% of visits. Of the non-responders at the end of the DBTP, 60/185 (32.4%) converted to ≥50% responders in at least half the visits and 24/185 (13.0%) converted to ≥50% responders in >80% of visits. Change from baseline at 112 weeks in mean (SD) MMD was −4.2 (5.0) days. Common AEs (≥10%) were nasopharyngitis, influenza and back pain.ConclusionsEfficacy was sustained over 112 weeks in individuals with difficult-to-treat EM for whom 2–4 prior migraine preventives had failed. Erenumab treatment was safe and well tolerated, in-line with previous studies.Trial registration numberNCT03096834

Marijuana, or Cannabis sativa L., is a common psychoactive plant used for both recreational and medicinal purposes. In many countries, cannabis-based medicines have been legalized under certain conditions because of their immense prospects in medicinal applications. With a comprehensive insight into the prospects and challenges associated with the pharmacological use and global trade of C. sativa, this mini-review focuses on the medicinal importance of the plant and its legal status worldwide; the pharmacological compounds and its therapeutic potential along with the underlying public health concerns and future perspective are herein discussed. The existence of major compounds including Δ9 -tetrahydrocannabinol (Δ9 -THC), cannabidiol, cannabinol, and cannabichromene contributes to the medicinal effects of the cannabis plant. These compounds are also involved in the treatment of various types of cancer, epilepsy, and Parkinson's disease displaying several mechanisms of action. Cannabis sativa is a plant with significant pharmacological potential. However, several aspects of the plant need an in-depth understanding of the drug mechanism and its interaction with other drugs. Only after addressing these health concerns, legalization of cannabis could be utilized to its full potential as a future medicine.

Tinea capitis (TC) is the most common dermatophyte infection in children. Fungal culture the gold standard diagnostic method takes several weeks and has poor yields. Trichoscopy helps in rapid diagnosis and could work as a monitoring tool during antifungal therapy. Our main objective is to document the evolution of trichoscopic features with treatment and their correlation with clinical parameters in patients of TC. Forty-six and 52 children with clinically diagnosed TC that was confirmed by potassium hydroxide microscopy, received griseofulvin and terbinafine, respectively. Recruited children were subjected to clinical and trichoscopic assessment by calculation of CASS (clinical assessment severity score) and counting of TAHC (Total Altered hair count; negative and positive), respectively, at baseline and follow-up at 2, 4, and 6 weeks. McNemar, Wilcoxon singed ranked test and Spearman-rho correlation of various parameters was evaluated. Follow-up trichoscopy revealed significant (p

Pancreas transplantation is an exciting therapy which has been used for several decades in the treatment of diabetes mellitus. It can be performed as either a whole organ or islet cell transplant. The role of interventional radiologists in the management of whole organ transplants is evolving and includes treatment of postoperative complications and graft biopsy to evaluate for rejection. An in-depth understanding of the transplant anatomy and variations is a fundamental tool in performing these interventions successfully. Islet cell transplantation entails delivery of purified donor pancreatic islet cells into the recipient portal vein. Because of their expertise in image-guided access to the portal system, interventional radiologists play a crucial role in this procedure. The purpose of this article is to review the indications, anatomy, complications, and outcomes of both whole organ and islet cell pancreas transplants, followed by a discussion of the role of interventional radiologists in each procedure.

An estimand clearly defines the target treatment effect to be estimated in a clinical trial. A recently published draft International Conference on Harmonization E9 addendum introduces the concept ...

Prior studies suggest an association between Vitamin K antagonists (VKA) and cerebral microbleeds (CMBs); less is known about nonvitamin K oral anticoagulants (NOACs). In this observational study we describe CMB profiles in a multicenter cohort of 89 anticoagulation‐related intracerebral hemorrhage (ICH) patients. CMB prevalence was 51% (52% in VKA‐ICH, 48% in NOAC‐ICH). NOAC‐ICH patients had lower median CMB count [2(IQR:1–3) vs. 7(4–11); P

IntroductionWe sought to evaluate the impact of pretreatment with intravenous thrombolysis (IVT) on the rate and speed of successful reperfusion (SR) in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT) in a high-volume tertiary care stroke center.MethodsConsecutive patients with ELVO treated with MT were evaluated. Outcomes were compared between patients who underwent combined IVT and MT (IVT+MT) and those treated with direct MT (dMT). The elapsed time between groin puncture to beginning of reperfusion (GPTBRT) and the numbers of device passes required to achieve SR were also documented.ResultsA total of 287 and 132 patients were treated with IVT+MT and dMT, respectively. The IVT+MT group had higher SR (73.8% vs 62.9%; p=0.023) and 3-month functional independence (modified Rankin Scale score 0–2;51.6% vs 38.2%; p=0.008) rates. The median GPTBRT was shorter in the IVT+MT group (48 (IQR 33–70) vs 70 (IQR 44–98) min; pConclusionsIVT pretreatment appears to increase the rates of SR and shortens the duration of the endovascular procedure by requiring fewer device passes in patients with ELVO treated with MT.

Health care transformation calls for patient engagement in quality improvement (PEQI), yet practice participation remains low. This pilot study of 8 primary care clinics at 7 statewide locations sought to determine the most effective strategies for disseminating a previously successful single-system PEQI intervention. Qualitative data were obtained through site visits, interviews, observations, and journaling. All material pertaining to barriers, recruitment/retention, and implementation was extracted, compared, and categorized. Five teams partially completed the intervention and 3 finished. These 3 teams did not ask for shorter trainings and were assigned a quality improvement (QI) coach. Multiple barriers to recruitment, implementation, and retention were noted at the organizational and clinic/team level, including turnover, shifting priorities, cross-level communication difficulties, lack of QI knowledge, and confusion between patient engagement and patient activation. These findings suggest that QI facilitation and dedicated time can help primary care teams identify and overcome barriers to PEQI.

Chronic invasive fungal rhino sinusitis (CIFS) is a well described clinical entity characterized by mucosal and sub mucosal infiltration of mycotic organisms and angio-centric extension into orbital and intracranial structures. Itraconazole, Voriconazole and Amphotericin B are commonly used for CIFS. In the present study we have evaluated short term clinical response of these drugs. Thirty diagnosed patients of CIFS who presented to us from January 2011 to December 2015 were divided into three groups randomly. Group A, B and C received Itraconazole, Voriconazole and Amphotericin respectively. Visual Analogue scale (VAS), Lund Mackay (LM) radiological scores and Kupferberg's nasal endoscopic grades were seen and compared in all patients before treatment, after primary surgical debridement and biopsy and after post biopsy antifungal drug treatment. We assessed the serum drug levels using HPLC assay at 4 and 8 weeks of therapy and correlated them for efficacy and safety. All the groups had significant improvement after treatment compared to beginning of study. Inter group comparison showed that mean LM, NE and VAS scores were significantly better in Voriconazole group compared to Itraconazole and amphotericin B therapy. The reduction of these objective parameters with treatment was also significantly high in Voriconazole group compared to the other two groups. Voriconazole has shown to be the most effective treatment modality for chronic invasive fungal sinusitis compared to other commonly used drugs such as Itraconazole and Amphotericin B.

BackgroundWe conducted a case-control study to assess the relative safety and efficacy of minimally invasive endoscopic surgery (MIS) for clot evacuation in patients with basal-ganglia intracerebral hemorrhage (ICH).MethodsWe evaluated consecutive patients with acute basal-ganglia ICH at a single center over a 42-month period. Patients received either best medical management according to established guidelines (controls) or MIS (cases). The following outcomes were compared before and after propensity-score matching (PSM): in-hospital mortality; discharge National Institutes of Health Stroke Scale score; discharge disposition; and modified Rankin Scale scores at discharge and at 3 months.ResultsAmong 224 ICH patients, 19 (8.5%) underwent MIS (mean age, 50.9±10.9; 26.3% female, median ICH volume, 40 (IQR, 25–51)). The interventional cohort was younger with higher ICH volume and stroke severity compared with the medically managed cohort. After PSM, 18 MIS patients were matched to 54 medically managed individuals. The two cohorts did not differ in any of the baseline characteristics. The median ICH volume at 24 hours was lower in the intervention group (40 cm3 (IQR, 25–50) vs 15 cm3 (IQR, 5–20); PConclusionsMinimally invasive endoscopic hematoma evacuation was associated with lower rates of in-hospital mortality in patients with spontaneous basal-ganglia ICH. These findings support a randomized controlled trial of MIS versus medical management for ICH.

Background: Tinea pseudoimbricata, characterized by concentric scaly rings simulating Tinea imbricata is caused by dermatophytes other than Trichophyton concentricum. It is reported to occur in patients with steroid abuse and in immunocompromised individuals. Aim: To study the clinico-mycological profile and dermoscopic features of T. pseudoimbricata in immunocompetent patients. Methods: We have evaluated 14 consecutive, clinically diagnosed patients of T. pseudoimbricata with positive 10% potassium hydroxide (KOH) examination and culture, seen over a period of 6 months. Dermoscopy was performed in all patients. The demographic, clinical, and mycological features of each patient were recorded on a predesigned proforma. Results: There were seven male and seven female patients with a mean age of 27.6 years and a mean disease duration of 3.8 months. All patients gave a history of application of potent or super-potent topical steroid with or without oral/injectable steroid for varying duration. Culture isolates were Trichophyton mentagrophytes complex and Trichophyton rubrum in 11 and 3 patients, respectively. Dermoscopic analysis showed features of steroid abuse in majority of the patients. Limitation: A small sample size was the limitation of our study. Conclusion: T. pseudoimbricata is a special subset of Tinea incognito caused by injudicious and inappropriate use of topical steroid. The typical appearance should alert the dermatologists regarding the possible abuse of steroids. Most common species isolated on culture was T. mentagrophytes complex.

Purpose We sought to evaluate the relationship between admission neutrophil-to-lymphocyte ratio (NLR) and functional outcome in aneurysmal subarachnoid hemorrhage (aSAH) patients. Material and methods Consecutive patients with aSAH were treated at two tertiary stroke centers during a five-year period. Functional outcome was defined as discharge modified Rankin score dichotomized at scores 0-2 (good) vs. 3-6 (poor). Results 474 aSAH patients were evaluated with a mean NLR 8.6 (SD 8.3). In multivariable logistic regression analysis, poor functional outcome was independently associated with higher NLR, older age, poorer clinical status on admission, prehospital statin use, and vasospasm. Increasing NLR analyzed as a continuous variable was independently associated with higher odds of poor functional outcome (OR 1.03, 95%CI 1.00-1.07, p=0.05) after adjustment for potential confounders. When dichotomized using ROC curve analysis, a threshold NLR value of greater than 6.48 was independently associated with higher odds of poor functional outcome (OR 1.71, 95%CI 1.07-2.74, p=0.03) after adjustment for potential confounders. Conclusions Higher admission NLR is an independent predictor for poor functional outcome at discharge in aSAH patients. The evaluation of anti-inflammatory targets in the future may allow for improved functional outcome after aSAH.

Background Lichen scrofulosorum (LS) represents immunologic reaction to the Mycobacterium tuberculosis antigen and presents with subtle, asymptomatic, grouped follicular papules over the trunk and shows good therapeutic response to antitubercular drugs. Objective To study the clinical and epidemiological characteristics of patients diagnosed with LS. Materials and methods A single-center retrospective review of patients diagnosed with LS from 1997 to 2018 was conducted. The data pertained to clinico-epidemiological profile, BCG vaccination, Mantoux positivity, laboratory investigations, coexistent focus of tuberculosis, and response to antitubercular treatment (ATT). Results LS cases constituted 15.2% (221/1458) of all the patients diagnosed with cutaneous tuberculosis (CTB). Of these, 156 (70.5%) were pediatric patients. All patients presented with multiple follicular and perifollicular grouped papules. The trunk was the most common site involved (98.6%), followed by lower limb (25.33%), upper limb (15.83%), face (5%), and external genitalia (3.6%). Evidence of BCG vaccination and Mantoux test positivity was observed in 52.03 and 83.2%, respectively. Coexistent TB focus was detected in 134 (60.6%) patients in lymph nodes, lungs, abdomen, and unusual sites such as intracranial, endometrium, and eye. Twenty-eight patients (12.66%) had coexistent other clinical forms of CTB. Clinical diagnosis of LS was confirmed on histology that revealed chiefly periappendageal epithelioid cell granuloma. Response to ATT was good with complete resolution of lesion in 8-12 weeks. Conclusion LS appears to be an underdiagnosed entity. Subtle and asymptomatic lesions of LS are often missed, thereby necessitating a high index of suspicion and appropriate evaluation of the underlying TB focus.

Background Muscle wasting and unintentional weight loss (cachexia) have been associated with worse outcomes in heart failure (HF), but timely identification of these adverse phenomena is difficult. Spot urinary creatinine may be an easily accessible marker to assess muscle loss and cachexia. This study investigated the association of urinary creatinine with body composition changes and outcomes in patients with new-onset or worsening HF (WHF).Methods In BIOSTAT-CHF, baseline spot urinary creatinine measurements were available in 2315 patients with new-onset or WHF in an international cohort (index cohort) and a validation cohort of 1431 similar patients from Scotland.Results Median spot urinary creatinine concentrations were 5.2 [2.7-9.6] mmol/L in the index cohort. Median age was 69 +/- 12 years and 73% were men. Lower spot urinary creatinine was associated with older age, lower height and weight, worse renal function, more severe HF, and a higher risk of >5% weight loss from baseline to 9 months (odds ratio = 1.23, 95% CI = 1.09-1.39 per log decrease; P = 0.001). Spot urinary creatinine was associated with Evans criteria of cachexia (OR = 1.26 per log decrease, 95% CI = 1.04-1.49; P = 0.016) and clustered with markers of heart failure severity in hierarchical cluster analyses. Lower urinary creatinine was associated with poorer exercise capacity and quality of life (both P < 0.001) and predicted a higher rate for all-cause mortality [hazard ratio (HR) = 1.27, 95% CI = 1.17-1.38 per log decrease; P < 0.001] and the combined endpoints HF hospitalization or all-cause mortality (HR = 1.23, 95% CI = 1.15-1.31 per log decrease; P < 0.001). Significance was lost after addition of the BIOSTAT risk model. Analyses of the validation cohort yielded similar findings.Conclusions Lower spot urinary creatinine is associated with smaller body dimensions, renal dysfunction, and more severe HF in patients with new-onset/WHF. Additionally, lower spot urinary creatinine is associated with an increased risk of weight loss and a poorer exercise capacity/quality of life. Urinary creatinine could therefore be a novel, easily obtainable marker to assess (risk of) muscle wasting in HF patients.

Background and Purpose: Stroke is reported as a consequence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in several reports. However, data are sparse regarding the details of these patients in a multinational and large scale. Methods: We conducted a multinational observational study on features of consecutive acute ischemic stroke, intracranial hemorrhage, and cerebral venous or sinus thrombosis among SARS-CoV-2–infected patients. We further investigated the risk of large vessel occlusion, stroke severity as measured by the National Institutes of Health Stroke Scale, and stroke subtype as measured by the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria among patients with acute ischemic stroke. In addition, we explored the neuroimaging findings, features of patients who were asymptomatic for SARS-CoV-2 infection at stroke onset, and the impact of geographic regions and countries’ health expenditure on outcomes. Results: Among the 136 tertiary centers of 32 countries who participated in this study, 71 centers from 17 countries had at least 1 eligible stroke patient. Of 432 patients included, 323 (74.8%) had acute ischemic stroke, 91 (21.1%) intracranial hemorrhage, and 18 (4.2%) cerebral venous or sinus thrombosis. A total of 183 (42.4%) patients were women, 104 (24.1%) patients were P =0.02) and higher rate of mechanical thrombectomy (12.4% versus 2%; P Conclusions: We observed a considerably higher rate of large vessel occlusions, a much lower rate of small vessel occlusion and lacunar infarction, and a considerable number of young stroke when compared with the population studies before the pandemic. The rate of mechanical thrombectomy was significantly lower in countries with lower health expenditures.

The STFM New Faculty Scholars Scholarship Webinar Series was created as part of the STFM Foundation New Faculty Scholars Program, ( ) which develops leadership and scholarship skills in a cohort of early career

The analgesic efficacy and safety of 2 phase 2b studies of EMA401 (a highly selective angiotensin II type 2 receptor antagonist) in patients with postherpetic neuralgia (EMPHENE) and painful diabetic neuropathy (EMPADINE) were reported. These were multicentre, randomised, double-blind treatment studies conducted in participants with postherpetic neuralgia or type I/II diabetes mellitus with painful distal symmetrical sensorimotor neuropathy. Participants were randomised 1:1:1 to either placebo, EMA401 25 mg, or 100 mg twice daily (b.i.d) in the EMPHENE and 1:1 to placebo or EMA401 100 mg b.i.d. in the EMPADINE. The primary outcome for both the studies was change in weekly mean of the 24-hour average pain score, using a numeric rating scale from baseline to week 12. Both the studies were prematurely terminated due to preclinical hepatotoxicity on long-term dosing, although not observed in these studies. Out of the planned participants, a total of 129/360 (EMPHENE) and 137/400 (EMPADINE) participants were enrolled. The least square mean reduction in numeric rating scale pain score was numerically in favour of EMA401 100 mg arm in both EMPHENE (treatment difference: -0.5 [95% confidence interval: -1.6 to 0.6; P value: 0.35]) and EMPADINE (treatment difference: -0.6 [95% confidence interval: -1.4 to 0.1; P value: 0.10]) at the end of week 12. However, as the studies were terminated prematurely, no firm conclusion could be drawn but the consistent clinical improvement in pain intensity reduction across these 2 studies in 2 different populations is worth noting.

BackgroundThe coronavirus disease (COVID-19) pandemic has affected stroke care globally. In this study, we aim to evaluate the impact of the current pandemic on racial disparities among stroke patients receiving mechanical thrombectomy (MT).MethodsWe used the prospectively collected data in the Stroke Thrombectomy and Aneurysm Registry from 12 thrombectomy-capable stroke centers in the US and Europe. We included acute stroke patients who underwent MT between January 2017 and May 2020. We compared baseline features, vascular risk factors, location of occlusion, procedural metrics, complications, and discharge outcomes between patients presenting before (before February 2020) and those who presented during the pandemic (February to May 2020).ResultsWe identified 2083 stroke patients: of those 235 (11.3%) underwent MT during the COVID-19 pandemic. Compared with pre-pandemic, stroke patients who received MT during the pandemic had longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4 days, PConclusionThe COVID-19 pandemic has affected the care process for stroke patients receiving MT globally. There is a significant decline in the number of African American patients receiving MT, which mandates further investigation.