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To assess the prevalence of abortion among population groups and changes in rates between 2008 and 2014.We used secondary data from the Abortion Patient Survey, the American Community Survey, and the National Survey of Family Growth to estimate abortion rates. We used information from the Abortion Patient Survey to estimate the lifetime incidence of abortion.Between 2008 and 2014, the abortion rate declined 25%, from 19.4 to 14.6 per 1000 women aged 15 to 44 years. The abortion rate for adolescents aged 15 to 19 years declined 46%, the largest of any group. Abortion rates declined for all racial and ethnic groups but were larger for non-White women than for non-Hispanic White women. Although the abortion rate decreased 26% for women with incomes less than 100% of the federal poverty level, this population had the highest abortion rate of all the groups examined: 36.6. If the 2014 age-specific abortion rates prevail, 24% of women aged 15 to 44 years in that year will have an abortion by age 45 years.The decline in abortion was not uniform across all population groups.

Introduction GOLD 2017 report proposed that the combined COPD assessment should be done according only to symptom burden and exacerbation history in the previous year. Objective This study aims to investigate the change in the COPD groups after the GOLD 2017 revision and also to discuss the evaluation of group C and D as a single group after the GOLD 2019 report. Method The study was designed as a cross-sectional. 251 stable COPD patients admitted to our out-patient clinic; aged ≥40 years, at least one-year diagnosis of COPD and ≥10 pack-year smoking history were consecutively recruited for the study. Results In GOLD 2017, a significant difference was found between the distribution of all groups compared to GOLD 2011 (P = 0,001). 31 patients included in group C were reclassified into group A and 37 patients in group D were reclassified into group B. The FEV1 values of group A and B patients were significantly low and group C and D patients had had exacerbations in more frequently the previous year in GOLD 2017 compared to GOLD 2011. Conclusion After the GOLD 2017 revision, the rate of group C patients decreased even more compared to GOLD 2011 and the group C and D may be considered as a single group in terms of the treatment recommendations with the GOLD 2019 revision. We think that future prospective studies are needed to support this suggestion.

In this report, we present a series of two unusual cases of elapid snakebite with acute neuroparalysis, that after initial response to standard anti-snake venom therapy, developed recurrence of disabling quadriparesis with dysautonomia, that on detailed evaluation turned out to be immune-mediated polyradiculoneuropathy (GB syndrome). Both the cases then responded to therapy with intravenous immunoglobulins. These cases bring out the rare immune-mediated late complication of snake venom, which if recognized and treated in time, can significantly reduce the morbidity and mortality.

Neurofibromatosis (NF) is an inherited neuroectodermal abnormality that primarily affects the growth of neural tissues, and Riccardi classified it into eight types. Segmental neurofibromatosis, which is a rare form of neurofibromatosis, is classified as type 5. We report a case for very unusual presentation of segmental NF with unilateral lisch nodules and uncommon sites involving the scalp. Moreover, we could find only one case report of segmental NF with lisch nodules in the literature and could not find any case report involving the scalp.

BACKGROUND Lacrosse is one of the fastest-growing sports in the United States. Its rules regarding permitted contact differ by sex and age. There are no known studies using a nationally representative data set to analyze lacrosse injury patterns over several years by sex and age in the youth population. METHODS A retrospective analysis was performed using data from the National Electronic Injury Surveillance System for youth aged 11-18 years who were treated for lacrosse-related injuries in U.S. emergency departments from 2000 to 2016. Based on our review of the case narratives, we created and coded a new injury-mechanism variable. We generated national estimates from 6406 cases. RESULTS An estimated 206,274 lacrosse-related injuries to youths aged 11-18 years were treated in U.S. emergency departments from 2000 to 2016. The rate of injuries per 10,000 significantly increased from 1.9 in 2000 to a peak of 5.3 in 2012 (p < 0.0001), followed by a significant decrease to 3.4 in 2016 (p = 0.020). Injury mechanism, body part injured, and diagnosis differed by sex. Boys were 1.62 times (95%CI: 1.25-2.09) more likely than girls to be injured by player-to-player contact. Girls were 2.21 times (95%CI: 1.96-2.49) more likely than boys to have non-contact injuries. Overall, as age increased, the percentage of injuries from lacrosse sticks decreased and player-to-player contact increased. CONCLUSION Despite additional protective regulations in the sport, lacrosse is an important source of injury where we continue to see differences by sex and age. This study supports the continuation, modification, and addition of rules aimed at reducing lacrosse injury risk.

Background Carbapenemase producing gram-negative bacteria (GNB) has become a huge problem in majority of tertiary care centers worldwide. They are associated with very high morbidity and mortality rates, especially when they cause invasive infections. Therefore, rapid detection of these organisms is very important for prompt and adequate antibiotic therapy as well as infection control. The aim of this study was rapid detection of carbapenemase genes and thereby likely carbapenem resistance, 24–48 hours in advance, directly from the positive-flagged blood culture bottles using CHROMagar and Xpert® Carba-R. Methods Aspirate from positively flagged blood culture bottles was subjected to differential centrifuge. All gram-negative bacilli on gram stain from the deposit were processed in Xpert® Carba-R and inoculated on CHROMagar. The presence of genes and growth on CHROMagar was compared with carbapenem resistance on VITEK-2 Compact. Results A total of 119 GNB isolates were processed. One or more of the carbapenemase genes were detected in 80 isolates. On comparison with VITEK-2 result, 92 samples showed concordance for carbapenem resistance 48 hours in advance. There was discordance in 21 isolates with 12 major errors and 09 minor errors. The sensitivity of direct Xpert® Carba-R test for rapid detection of carbapenem resistance, 48 hours in advance, was 81.42%. The sensitivity of direct CHROMagar test for accurate detection of carbapenem resistance, 24 hours in advance, was 92.06%. Conclusion The ability to detect carbapenem resistance with very high accuracy, 48 hours in advance, helps in appropriate antibiotic therapy and implementation of effective infection control practices.

Many systemic diseases go along with dermal involvement. Only a few of systemic diseases show characteristic skin derangements directly leading to the diagnosis of the underlying disease. Ten of these entities are described within this article. Some of these are autoimmune diseases, such as systemic lupus erythematodes, dermatomyositis or the anti-synthetase-syndrome. Others are genetic diseases with benign or malignant neoplasias (Peutz-Jeghers-syndrome, neurofibromatosis, tuberous sclerosis, Birt-Hogg-Dubé-syndrome, Cowden-syndrome). Other genetically based diseases with typical skin manifestations are characterised by vascular malformations (Pseudoxanthoma elasticum and Osler-Weber-Rendu syndrome) or metabolic and structural organ defects (Morbus Fabry, cystic fibrosis). Being familiar with the typical skin-appearance of these diseases will allow physicians and general practitioners to make a timely diagnosis.

Background Injury surveillance is the cornerstone of any prevention program. However the same pertaining to women’s boxing is meager. We hence intended to analyse the incidence, pattern and characteristics of injuries in female boxers during the 4th Elite Women’s National Boxing Championship, 2019, in India. Methods A total of 235 female Indian boxers participated in the tournament. Injuries from the competition injury database maintained in accordance with the injury code proposed by the Australian Sports Injury Data Dictionary were compiled to observe the pattern and analysed. The outcomes measured were incidence in terms of injury rate and injury risk and injury pattern in terms of site, nature, mechanism, severity and time of injury. Results The injury rate was observed to be 43.98 injuries per 1000 athlete bouts of exposure (95% confidence interval [CI]: 33.71-54.07) and 293.21 injuries per 1000 athlete hours of competition (95% CI: 225.94-360.47). The most commonly injured site was head, face and neck regions. Most injuries were bruises/contusions followed by cuts and epistaxis. No concussions were reported. Conclusion This study observed that women are less prone to injuries than their male counterparts, even though a logical comparison is difficult because of the lack of data and standardization in women's boxing.

• The presentation of urinary tract infections (UTIs) in neonates differs from that seen in older children. • The type and route of infection also differ in neonates, when compared with older children. • An appropriate urine sample for diagnosis is needed, but treatment should not be delayed. • A neonate in whom a UTI is suspected should be evaluated for sepsis, including invasive cultures. • After a documented neonatal UTI, a radiologic work-up is warranted to detect anatomic anomalies. • Vesicoureteral reflux (VUR) is diagnosed in 30%–50% of neonates with proven UTI. • Voiding cystourethrogram is the gold standard for the diagnosis of VUR and should be performed on high-risk neonates. • Treatment of VUR should be tailored to each patient's individual risk of UTI recurrence, with the goals of preventing future UTIs and renal scar formation.

BACKGROUND: The association between obesity (body mass index (BMI) ≥ 30 kg/m(2)) and pattern of medication use during pregnancy in the United States is not well-studied. Higher prepregnancy BMI may be associated with increases or decreases in medication use across pregnancy as symptoms (e.g. reflux) or comorbidities (e.g. gestational diabetes) requiring treatment that may be associated with higher BMI could also change with advancing gestation. OBJECTIVES: To determine whether prenatal medication use, by the number and types of medications, varies by pre-pregnancy obesity status. METHODS: In a secondary data analysis of a racially/ethnically diverse prospective cohort of pregnant women with low risk for fetal abnormalities enrolled in the first trimester of pregnancy and followed to delivery (singleton, 12 United States clinical sites), free text medication data were obtained at enrollment and up to five follow-up visits and abstracted from medical records at delivery. RESULTS: In 436 women with obesity and 1750 women without obesity (pre-pregnancy BMI, 19–29.9 kg/m(2)), more than 70% of pregnant women (77% of women with and 73% of women without obesity) reported taking at least one medication during pregnancy, respectively (adjusted risk ratio (aRR)=1.10, 95% confidence interval (CI)=1.01, 1.20), with 81% reporting two and 69% reporting three or more. A total of 17 classes of medications were identified. Among medication classes consumed by at least 5% of all women, the only class that differed between women with and without obesity was hormones and synthetic substitutes (including steroids, progesterone, diabetes, and thyroid medications) in which women with obesity took more medications (11 vs. 5%, aRR = 1.9, 95% CI = 1.38, 2.61) compared to women without obesity. Within this class, a higher percentage of women with obesity took diabetes medications (2.3 vs. 0.7%) and progesterone (3.4 vs. 1.3%) than their non-obese counterparts. Similar percentages of women with and without obesity reported consuming medications in the remaining medication classes including central nervous system agents (50 and 46%), gastrointestinal drugs (43 and 40%), anti-infective agents (23 and 21%), antihistamines (20 and 17%), autonomic drugs (10 and 9%), and respiratory tract agents (7 and 6%), respectively (p > 0.05 for all adjusted comparisons). There were no differences in medication use by obesity status across gestation. Since the study exclusion criteria limited the non-obese group to women without thyroid disease, in a sensitivity analysis we excluded all women who reported thyroid medication intake and still a higher proportion of women with obesity took the hormones and synthetic substitutes class compared to women without obesity. CONCLUSION: Our findings suggest that pre-pregnancy obesity in otherwise healthy women is associated with a higher use of only selected medications (such as diabetes medications and progesterone) during pregnancy, while the intake of other more common medication types such as analgesics, antibiotics, and antacids does not vary by pre-pregnancy obesity status. As medication safety information for prenatal consumption is insufficient for many medications, these findings highlight the need for a more in-depth examination of factors associated with prenatal medication use.

Summary Surgeons and their patients recognise that one of the major advances in surgical technique over the last 20 years has been the growth of minimal access surgery by means of laparoscopic and robotic approaches. Partnerships with industry have facilitated the development of advanced technical instruments, light sources, recording devices and optics which are almost out of date by the time they are introduced to surgical practice. However, lest we think that technological innovation is entirely a modern concept, we should remember that our predecessors were masters of their craft and able to apply new technologies to surgical practice. The history of minimal access surgery can be traced back to approximately 5000 years ago and this review aims to remind us of the achievements of historical doctors and engineers, as well as bring more modern developments to wider attention. This review will comprise a three-part series: Part I 3000BC to 1850 Early instruments for viewing body cavities Part II 1850 to 1990 Technological developments Part III 1990 to present Organisational issues and the rise of the robots

Background: The optimal vasopressor management for septic patients with left ventricular (LV) dysfunction has not been well established, and current evidence is conflicting regarding the optimal vasopressor discontinuation order. Objective: The objective was to evaluate the impact of LV dysfunction on the hemodynamic management of septic shock by assessing the incidence of clinically significant hypotension after vasopressor discontinuation. Methods: In this single-center, retrospective cohort study, adult patients were included if they met the Sepsis-3 definition of septic shock, had LV dysfunction (defined as an ejection fraction ≤40%), and received norepinephrine and vasopressin as the last vasopressors discontinued. The primary outcome was the incidence of clinically significant hypotension following discontinuation of vasopressin or norepinephrine. Clinically significant hypotension was defined as a MAP less than 60 mmHg and the need for either: 1) the reinstitution of the previously discontinued agent at any dosage, 2) the receipt of at least 500 mL of a crystalloid at a rate of at least 500 mL/hour, 3) or the receipt of at least 25 grams of albumin 5% at a rate of at least 25 gram/hour. Secondary outcomes included intensive care unit (ICU) and hospital lengths of stay, and ICU and hospital mortality. Results: A total of 78 patients met inclusion criteria, with 37 patients having vasopressin discontinued first and 41 having norepinephrine discontinued first. Clinically significant hypotension occurred in 28 patients (76%) following the discontinuation of vasopressin, compared to 28 patients (81%) following the discontinuation of norepinephrine (p = 0.61). ICU length of stay was 9 days in the vasopressin discontinued first cohort, compared to 15 days in the norepinephrine discontinued first cohort (p = 0.01). There was no statistically significant difference in mortality observed. Conclusion: The discontinuation order of norepinephrine and vasopressin did not impact the incidence of clinically significant hypotension in patients with septic shock and LV dysfunction, but may influence ICU length of stay, although other factors may have impacted this finding.

Inhaled antibiotics are commonly used to treat persistent airway infection with Pseudomonas aeruginosa that contributes to lung damage in people with cystic fibrosis. Current guidelines recommend inhaled tobramycin for individuals with cystic fibrosis and persistent Pseudomonas aeruginosa infection who are aged six years or older. The aim is to reduce bacterial load in the lungs so as to reduce inflammation and deterioration of lung function. This is an update of a previously published review.To evaluate the effects of long-term inhaled antibiotic therapy in people with cystic fibrosis on clinical outcomes (lung function, frequency of exacerbations and nutrition), quality of life and adverse events (including drug-sensitivity reactions and survival).We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries. Date of last search: 28 June 2022.We selected trials where people with cystic fibrosis received inhaled anti-pseudomonal antibiotic treatment for at least three months, treatment allocation was randomised or quasi-randomised, and there was a control group (either placebo, no placebo or another inhaled antibiotic).Two authors independently selected trials, judged the risk of bias, extracted data from these trials and judged the certainty of the evidence using the GRADE system.The searches identified 410 citations to 125 trials; 18 trials (3042 participants aged between five and 45 years) met the inclusion criteria. Limited data were available for meta-analyses due to the variability of trial design and reporting of results. A total of 11 trials (1130 participants) compared an inhaled antibiotic to placebo or usual treatment for a duration between three and 33 months. Five trials (1255 participants) compared different antibiotics, two trials (585 participants) compared different regimens of tobramycin and one trial (90 participants) compared intermittent tobramycin with continuous tobramycin alternating with aztreonam. One trial (18 participants) compared an antibiotic to placebo and also to a different antibiotic and so fell into both groups. The most commonly studied antibiotic was tobramycin which was studied in 12 trials. Inhaled antibiotics compared to placebo We found that inhaled antibiotics may improve lung function measured in a variety of ways (4 trials, 814 participants). Compared to placebo, inhaled antibiotics may also reduce the frequency of exacerbations (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.47 to 0.93; 3 trials, 946 participants; low-certainty evidence). Inhaled antibiotics may lead to fewer days off school or work (quality of life measure) (mean difference (MD) -5.30 days, 95% CI -8.59 to -2.01; 1 trial, 245 participants; low-certainty evidence). There were insufficient data for us to be able to report an effect on nutritional outcomes and there was no effect on survival. There was no effect on antibiotic resistance seen in the two trials that were included in meta-analyses. We are uncertain of the effect of the intervention on adverse events (very low-certainty evidence), but tinnitus and voice alteration were the only events occurring more often in the inhaled antibiotics group. The overall certainty of evidence was deemed to be low for most outcomes due to risk of bias within the trials and imprecision due to low event rates. Different antibiotics or regimens compared Of the eight trials comparing different inhaled antibiotics or different antibiotic regimens, there was only one trial for each unique comparison. We found no differences between groups for any outcomes except for the following. Aztreonam lysine for inhalation probably improved forced expiratory volume at one second (FEVsub1/sub) % predicted compared to tobramycin (MD -3.40%, 95% CI -6.63 to -0.17; 1 trial, 273 participants; moderate-certainty evidence). However, the method of defining the endpoint was different to the remaining trials and the participants were exposed to tobramycin for a long period making interpretation of the results problematic. We found no differences in any measure of lung function in the remaining comparisons. Trials measured pulmonary exacerbations in different ways and showed no differences between groups except for aztreonam lysine probably leading to fewer people needing treatment with additional antibiotics than with tobramycin (RR 0.66, 95% CI 0.51 to 0.86; 1 trial, 273 participants; moderate-certainty evidence); and there were fewer hospitalisations due to respiratory exacerbations with levofloxacin compared to tobramycin (RR 0.62, 95% CI 0.40 to 0.98; 1 trial, 282 participants; high-certainty evidence). Important treatment-related adverse events were not very common across comparisons, but were reported less often in the tobramycin group compared to both aztreonam lysine and colistimethate. We found the certainty of evidence for these comparisons to be directly related to the risk of bias within the individual trials and varied from low to high.Long-term treatment with inhaled anti-pseudomonal antibiotics probably improves lung function and reduces exacerbation rates, but pooled estimates of the level of benefit were very limited. The best evidence available is for inhaled tobramycin. More evidence from trials measuring similar outcomes in the same way is needed to determine a better measure of benefit. Longer-term trials are needed to look at the effect of inhaled antibiotics on quality of life, survival and nutritional outcomes.

Background: Management of scaphoid nonunions with bone loss varies substantially. Commonly, internal fixation consists of a single headless compression screw. Recently, some authors have reported on the theoretical benefits of dual-screw fixation. We hypothesized that using 2 headless compression screws would impart improved stiffness over a single-screw construct. Methods: Using a cadaveric model, we compared biomechanical characteristics of a single tapered 3.5- to 3.6-mm headless compression screw with 2 tapered 2.5- to 2.8-mm headless compression screws in a scaphoid waist nonunion model. The primary outcome measurement was construct stiffness. Secondary outcome measurements included load at 1 and 2 mm of displacement, load to failure for each specimen, and qualitative assessment of mode of failure. Results: Stiffness during load to failure was not significantly different between single- and double-screw configurations ( P = .8). Load to failure demonstrated no statistically significant difference between single- and double-screw configurations. Using a qualitative assessment, the double-screw construct maintained rotational stability more than the single-screw construct ( P = .029). Conclusions: Single- and double-screw fixation constructs in a cadaveric scaphoid nonunion model demonstrate similar construct stiffness, load to failure, and load to 1- and 2-mm displacement. Modes of failure may differ between constructs and represent an area for further study. The theoretical benefit of dual-screw fixation should be weighed against the morphologic limitations to placing 2 screws in a scaphoid nonunion.

Background Instrument oversupply drives cost in the operating room (OR). We review previously reported methodologies for surgical instrument reduction and report a pilot methodology for optimizing instrument supply via ethnographic instrument tracking of thumb carpometacarpal (CMC) arthroplasties. Additionally, we report a cost analysis of instrument oversupply and potential savings of tray optimization methods. Methods Instrument utilization was tracked over 8 CMC arthroplasties conducted by 2 surgeons at an ambulatory surgery center of a large academic hospital. An optimized supply methodology was designed. A cost analysis was conducted using health-system-specific data and previously published research. Results After tracking instrument use in 8 CMC arthroplasties, a cumulative total of 59 out of the 120 instruments in the Hand & Foot (H&F) tray were used in at least 1 case. Two instruments were used in all cases, and another 20 instruments were used in at least 50% of the cases. Using a reduced tray with 59 instruments, potential cost savings for tray reduction in 60 cases were estimated to be $2086 without peel-packing and $2356 with peel-packing. The estimated cost savings were lower than those reported in literature due to a reduced scope and exclusion of OR time cost in the analysis. Conclusions Instrument oversupply drives cost at our institution’s ambulatory surgery center. Ethnography is a cost-effective method to track instrument utilization and determine optimal tray composition for small services but is not scalable to large health systems. The time and cost required to observe sufficient surgeries to enable supply reduction to motivate the need for more efficient methods to determine instrument utility.

Background: Actionable feedback from patients after a clinic visit can help inform ways to better deliver patient-centered care. A 2-word assessment may serve as a proxy for lengthy post-visit questionnaires. We tested the use of a 2-word assessment in an outpatient hand clinic. Methods: New patients were asked to provide a 2-word assessment of the following: (1) their physician; (2) their overall experience; and (3) recommendations for improvement and their likelihood to recommend (LTR) after their clinic visit. Sentiment analysis was used to categorize results into positive, neutral, or negative sentiment. Recommendations for improvement were classified into physician issue, system issue, or neither. We evaluated the relationship between LTR status, sentiment, actionable improvement opportunities, and classification (physician issue, system issue, or neither). Recommendations for improvement were classified into themes based on prior literature. Results: Sixty-seven (97.1%) patients noted positive sentiment toward their physician; 67 (97.1%) noted positive sentiment toward their overall experience. About 31% of improvement recommendations were system-based, 5.9% were physician-based, and 62.7% were neither. Patients not LTR were more likely to leave actionable opportunities for improvement than those LTR ( P = .01). Recommendations for improvement were classified into predetermined themes relating to: (1) physician interaction; (2) check-in process; (3) facilities; (4) unnecessary visit; and (5) appointment delays. Conclusion: Patients not likely to recommend provided actionable opportunities for improvement using a simple 2-word assessment. Implementation of a 2-word assessment in a hand clinic can be used to obtain actionable, real-time patient feedback that can inform operational change and improve the patient experience.

Background: Social and demographic factors may influence patient treatment by physicians. This study analyzes the influence of patient sociodemographics on prescription practices among hand surgeons. Methods: We performed a retrospective analysis of all hand surgeries (N = 5278) at a single academic medical center from January 2016 to September 2018. The average morphine milligram equivalent (MME) prescribed following each surgery was calculated and then classified by age, race, sex, type of insurance, and history of substance use or chronic pain. Multivariate linear regression was used to compare MME among groups. Results: Overall, patients with a history of substance abuse were prescribed 31.2 MME more than those without ( P < .0001), and patients with a history of chronic pain were prescribed 36.7 MME more than those without ( P < .0001). After adjusting for these variables and the type of procedure performed, women were prescribed 11.2 MME less than men ( P = .0048), and Hispanics were prescribed 16.6 MME more than whites ( P = .0091) overall. Both Hispanic and black patients were also prescribed more than whites following carpal tunnel release (+19.0 and + 20.0 MME, respectively; P < .001). Patients with private insurance were prescribed 24.5 MME more than those with Medicare ( P < .0001), but 25.0 MME less than those with Medicaid ( P < .0001). There were no differences across age groups. Conclusions: Numerous sociodemographic factors influenced postoperative opioid prescription among hand surgeons at our institution. These findings highlight the importance of establishing more uniform, evidence-based guidelines for postoperative pain management, which may help minimize subjectivity and prevent the overtreatment or undertreatment of pain in certain patient populations.

Background: The Rhode Island State Legislature passed the Uniform Controlled Substances Act in 2016 to limit opioid prescriptions. We aimed to objectively evaluate its effect on opioid prescribing for hand surgery patients and also identify risk factors for prolonged opioid use. Methods: A 6-month period (January-June 2016) prior to passage of the law was compared with a period following its implementation (July-December 2017). Thumb carpometacarpal arthroplasty and distal radius fracture fixation were classified as “major surgery” and carpal tunnel and trigger finger release as “minor surgery.” Prescription Drug Monitoring Database was used to review controlled substances filled during the study periods. Results: A total of 1380 patients met our inclusion criteria, with 644 prelaw and 736 postlaw patients. Patients undergoing “major surgery” saw a significant decrease in the number of pills issued in the first postoperative prescription (41.1 vs 21.0) and a corresponding decrease in morphine milligram equivalents (MMEs) (318.6 vs 159.2 MMEs) after implementation. A 30% decrease in MMEs was also seen in those undergoing “major surgery” in the first 30 days postoperatively (544.7 vs 381.7 MMEs). Risk factors for prolonged opioid use included male sex and preoperative opioid use. Conclusions: In Rhode Island, opioid-limiting legislation resulted in a significant decrease in the number of pills and MMEs of the initial prescription and a 30% decrease in total MMEs in the 30-day postoperative period after “major hand surgery.” Additional research is needed to explore the association between legislation and clinical outcomes.

Background: In treating occupational hand injuries under workers’ compensation, the 2 most important goals are to maximize patient function, ideally to preinjury levels, and permit a timely return to work (RTW). The purpose of this study was to determine factors affecting total case length, that is, the total time from injury until primary closure of a patient’s claim, and disposition among patients with hand injuries treated under workers’ compensation. Methods: All cases treated under workers’ compensation by a single fellowship-trained hand surgeon within a single year were retrospectively reviewed. A case is defined as the entire management and treatment of a single patient related to a single occupational injury incident. Independent variables included age, sex, body mass index, comorbidity, occupation, injury pattern, and treatment modality. Dependent variables included treatment duration from injury to case closure and final case disposition (RTW, functional capacity evaluation [FCE], or loss to follow-up [LTFU]). Comparison between groups was accomplished with analysis of variance. Multivariate linear and logistic regression analysis was performed to predict case length and disposition. Results: In all, 447 cases involving a workers’ compensation claim were reviewed. Among these, 75 (16.8%) were LTFU, 24 (5.4%) required an FCE, and 346 (77.4%) an RTW. The RTW cases averaged 138.5 days, whereas those requiring FCE averaged 331.5 days. Compared with average case length, crush injuries (76.8 days. P < .001) and fractures (111.8 days, P = .0224) had significantly shorter time to closure. In a multivariate linear model, cases of soft tissue and nerve injury were associated with longer case lengths, remaining open for an additional 56.8 and 347.1 days, respectively ( P < .001). Each treatment modality studied, therapy, injections, and surgery, was associated with an increase in case length. Conclusions: Cases requiring FCE were open significantly longer than those resulting in RTW. In addition, injury pattern and treatment modality were associated with significant variations in total case length. These results imply that a specific subset of patients, namely those with soft tissue and nerve injuries, may experience delayed resolution among patients treated under a workers’ compensation claim.

Tamoxifen exposure is a recognised risk for primary endometrial cancer. This case serves as a reminder to meticulously check the past medical history and inform patients of the risk-benefit of treatment as part of a shared-decision making process.

This study was set out to explore the understanding of dementia as a culturally and socially shaped illness in order to illuminate such perceptions and experience in relation to ethnoculturally profiled dementia care in Sweden. The results indicate, contrary to many other studies (c.f. Conell et al 2009; Flaskerud 2009; Gray et al 2009; Hinton, Franz & Friend 2004) that the perception of dementia and the described meaning of the disease have little (or nothing) to do with decisions regarding formal care. However, cultural norms and traditions in relation to issues of filial piety seem to do. Thus, to understand how different ethnocultural groups might respond to dementia care within a migratory context, the current study illuminate the fact that it is crucial to realize that neither the individual person with dementia, nor larger ethnocultural groups can be placed within a vacuum that seemingly does not change or correlate with surrounding society.

Operationsverfahren sowie Liegezeiten und Altersgrenzen haben sich in den letzten Jahren bei hüftendoprothetischer Versorgung geändert. Während sich Krankenhäuser immer mehr spezialisieren und Patienten teilweise bereits nach 3–4 Tagen in die Anschlussrehabilitation entlassen, muss die nachversorgende Rehabilitationsklinik einen differenzierten Behandlungspfad vorhalten, um den unterschiedlichen Anforderungen und Bedürfnissen zwischen Fast-Track-Chirurgie und Orthogeriatrie gerecht zu werden.

Introduction Clozapine is an atypical antipsychotic drug eligible for treatment-resistant schizophrenia. It frequently represents the best and the only choice in resistant schizophrenia. However, its use is feared by many professionals due to its possible adverse effects, such as eosinophilia. Case report We report a case of a young white male suffering from treatment-resistant schizophrenia who rapidly developed eosinophilia after starting clozapine. Discussion We present a case of a 26-year-old white man diagnosed with schizophrenia with poor clinical response to several antipsychotics owing to which clozapine was started. Psychotic symptoms improved dramatically but a progressively ascendant eosinophilia was reported during serial haematological analyses. The patient remained physically asymptomatic. An exhaustive assessment with ancillary diagnostic tests revealed no cause for eosinophilia. Thus, a diagnosis of clozapine-induced eosinophilia was made. The drug was discontinued and eosinophil count progressively returned to normal but psychotic symptoms worsened. Conclusions Clozapine treatment is frequently feared due to its possible side effects and complications, delaying its use in refractory schizophrenia. Also, to our knowledge, there are no specific guidelines on how to manage haematological side effects such as eosinophilia. This is problematic as, in some cases, it may lead to an unnecessary withdrawal of clozapine with a worsening of psychotic symptoms. We present a brief discussion of the recent literature on the subject.

Key Points Question Are results of universal and selective screening for suicide risk implemented in a pediatric emergency department associated with future suicidal behaviors? Findings In this cohort study of 15 003 youths aged 8 to 18 years, positive screens were significantly associated with subsequent suicide-related hospital visits compared with standard emergency department procedures. Screening also more than doubled the detection of suicide risk compared with treatment as usual. Meaning These findings suggest that screening for suicide risk in pediatric emergency departments is an effective approach to identify risk for subsequent suicide-related emergency department visits., This cohort study examines the association between results of universal and selective screening for suicide risk in a pediatric emergency department using the Ask Suicide-Screening Questions (ASQ) instrument and subsequent suicide-related outcomes., Importance According to National Patient Safety Goal 15.01.01, all individuals being treated or evaluated for behavioral health conditions as their primary reason for care in hospitals and behavioral health care organizations accredited by The Joint Commission should be screened for suicide risk using a validated tool. Existing suicide risk screens have minimal or no high-quality evidence of association with future suicide-related outcomes. Objective To test the association between results of the Ask Suicide-Screening Questions (ASQ) instrument in a pediatric emergency department (ED), implemented through selective and universal screening approaches, and subsequent suicide-related outcomes. Design, Setting, and Participants In this retrospective cohort study at an urban pediatric ED in the United States, the ASQ was administered to youths aged 8 to 18 years with behavioral and psychiatric presenting problems from March 18, 2013, to December 31, 2016 (selective condition), and then to youths aged 10 to 18 years with medical presenting problems (in addition to those aged 8-18 years with behavioral and psychiatric presenting problems) from January 1, 2017, to December 31, 2018 (universal condition). Exposure Positive ASQ screen at baseline ED visit. Main Outcomes and Measures The main outcomes were subsequent ED visits with suicide-related presenting problems (ie, ideation or attempts) based on electronic health records and death by suicide identified through state medical examiner records. Association with suicide-related outcomes was calculated over the entire study period using survival analyses and at 3-month follow-up for both conditions using relative risk. Results The complete sample was 15 003 youths (7044 [47.0%] male; 10 209 [68.0%] black; mean [SD] age, 14.5 [3.1] years at baseline). The follow-up for the selective condition was a mean (SD) of 1133.7 (433.3) days; for the universal condition, it was 366.2 (209.2) days. In the selective condition, there were 275 suicide-related ED visits and 3 deaths by suicide. In the universal condition, there were 118 suicide-related ED visits and no deaths during the follow-up period. Adjusting for demographic characteristics and baseline presenting problem, positive ASQ screens were associated with greater risk of suicide-related outcomes among both the universal sample (hazard ratio, 6.8 [95% CI, 4.2-11.1]) and the selective sample (hazard ratio, 4.8 [95% CI, 3.5-6.5]). Conclusions and Relevance Positive results of both selective and universal screening for suicide risk in pediatric EDs appear to be associated with subsequent suicidal behavior. Screening may be a particularly effective way to detect suicide risk among those who did not present with ideation or attempt. Future studies should examine the impact of screening in combination with other policies and procedures aimed at reducing suicide risk.

Background Cancer incidence is rising across the globe. The incidence and patterns of various cancers among Armed Forces Personnel and Veterans is not known. We did the analysis of registry data maintained at our hospital. Methods A retrospective analysis was performed of all patients registered at our hospital cancer registry between 01st January 2017 and 31st December 2019. Patients were registered with unique identification number. Baseline demographics and cancer subtype data were retrieved. Patients with histopathologically proven diagnosis and age ≥18 years were studied. Armed Forces Personnel (AFP) were defined as those who are in active service, and Veterans as those who had retired from service at the time of registration. Patients with Acute and Chronic Leukemias were excluded. Results New cases registered were 2023, 2856 and 3057 in year 2017, 2018, 2019 respectively. AFP, Veterans and dependents among them were 9.6%, 17.8%, and 72.6% respectively. Haryana, Uttar Pradesh and Rajasthan represented 55% of all cases with male to female ratio 1.14:1 and median age was 59 years. The median age among AFP was 39 years. Among AFP as well as veterans, Head and Neck cancer was the most common malignancy. Cancer incidence was significantly higher in adults >40 years as compared to Conclusion Seven percent rise per year of new cases in this cohort is alarming. Tobacco-related cancers were the most common. There is an unmet need to establish a prospective centralized Cancer Registry to better understand the risk factors, outcomes of treatment and strengthen the policy matters.

Background Latent tuberculosis infection (LTBI) diagnosis in a country with a low tuberculosis burden is complicated. Since the prevalence of LTBI in second generation immigrants has not been well recognized, we conducted a cross-sectional study which aimed to explore the differences in LTBI prevalence between offspring of immigrants from high tuberculosis (TB) burden countries and those whose parents were born in countries with a low TB burden. Methods Between May 2014 and April 2018 young native Israelis who were required to perform pre-occupational tuberculin skin tests (TST) (medical and paramedical personnel or teaching assistants of immigrants from high TB burden countries) and who had a TST result of 10 mm and above were tested for QuantiFERON-TB In Tube (QFT-GIT). Statistical comparisons were made between second generation immigrants and those with both parents from a low TB burden country. Results Of 102 patients, 71 were born to parents both of whom were from low-risk countries, 14 to one parent from a high-risk country and 17 to parents both of whom were from a high-risk country. The odds ratio for LTBI was 4.5 (95% CI, 1.2–17.2; p = 0.03) if both parents were born in a high-risk country compared to both parents being from a low-risk country and 4.01 (95% CI, 1.12–14.3; p = 0.03) higher compared to persons for whom at least one parent was born in a low-risk country. Conclusion The risk for latent TB is significantly higher in second generation immigrants if both parents were born in a high-risk country. IGRA should be considered before treatment to patients with a positive TST if at least one parent was born in a low-risk country in order to confirm LTBI.

Tuberous sclerosis complex (TSC) and autosomal dominant polycystic kidney disease (ADPKD) are conditions related to renal failure that can rarely occur in association as a contiguous gene syndrome. Angiomyolipomas (AMLs) are renal tumors strongly related to TSC that may rupture and cause life-threatening bleedings. We present a patient with TSC, ADPKD, and renal AMLs with persistent hematuria requiring blood transfusion. The persistent hematuria was successfully treated through endovascular embolization, a minimally invasive nephron sparing technique. Keywords: Tuberous Sclerosis; Polycystic [...]

Background Male osteoporosis is under-diagnosed and poorly studied. With the ageing population, osteoporotic fracture in men is an emerging health problem. The aim of this study was to study the prevalence of osteoporosis and its association with serum testosterone and serum vitamin D in elderly men (>60 years old) attending the outpatient department (OPD). Methods An observational cross-sectional study was performed in elderly men (>60 years old) attending OPD of a tertiary care hospital of Western Maharashtra between April 2017 and June 2019. Patients with rheumatological disorders, history of vertebral/femoral fractures, chronic kidney disease, chronic liver disease, thyroid disorders and alcohol dependence were excluded. Data were analysed using the chi-square test and descriptive statistics. Results In total, 408 male patients were included. The mean age was 68.33 years. Osteoporosis was seen in 39.5% of patients (161/408) with a T score of ≤2.5. Osteopenia was noted in 48.3% of patients (197/408). T and Z scores had significant correlation (p = Conclusion Osteoporosis was noted in 39.5% of the elderly men. In addition, decreased testosterone, COPD and BPH were significantly associated with male osteoporosis. It is important to screen elderly men to diagnose osteoporosis early and prevent osteoporotic fractures.

Empagliflozin has a demonstrated cardiovascular benefit. It is co-prescribed as a glucose-lowering medication in patients with type II diabetes mellitus. Herein, we discuss dual-emergency side-effects, Fournier's gangrene (FG) and diabetic ketoacidosis with lower-than-anticipated glucose levels in a patient on Empagliflozin, a sodium-glucose transport protein 2 inhibitor (SGLT-2i). The pathophysiologic mechanism of FG in correlation with SGLT-2i is not yet elucidated. SGLT-2i increase predisposition to genital mycotic and urinary infections, a mechanism favouring FG. A patient with type II diabetes mellitus on SGLT-2i presented with acute necrotic infection of the scrotum and simultaneous diabetic ketoacidosis with lower-than-anticipated glucose levels. This dual emergency was managed with debridement and medical treatment on lines of diabetes ketoacidosis, respectively. A re-look at this group of glucose-lowering medications from bedside towards benchtop research may help to prod into any other mechanistic basis of these life-threatening clinical occurrences.

Background Non-small cell lung cancer (NSCLC) is the most common type of lung cancer with a high mortality rate and poor prognosis. miR-637 has been reported to regulate tumor progression and act as a prognosis biomarker of various cancers. Its functional role in NSCLC was investigated in this study. Methods The expression level of miR-637 in NSCLC tissues and adjacent normal tissues of 123 NSCLC patients was analyzed by qRT-PCR. The association between miR-637 and clinical pathological features in the prognosis of patients was analyzed. Cell transfection was performed to overexpress or knockdown miR-637 in H1299 and HCC827. The proliferation, migration, and invasion of H1299 and HCC827 were evaluated by CCK8 and Transwell assay. Results miR-637 expression was significantly decreased in NSCLC tissues and cell lines relative to normal tissues and cells. The survival rate of NSCLC patients with low miR-637 expression was lower than that of patients with high miR-637 expression. Additionally, miR-637 served as a tumor suppressor that inhibited cell proliferation, migration, and invasion of NSCLC. Conclusion Downregulation of miR-637 in NSCLC was associated with TNM stage and poor prognosis of patients and served as a tumor suppressor in NSCLC. These results provide a potential strategy to control NSCLC.

Background The objective of this study was to evaluate pattern and distribution of neovascularization of optic disc (NVD) and elsewhere (NVE) in proliferative diabetic retinopathy (PDR). Methods A cross-sectional study was conducted among freshly detected cases of PDR. Fundus fluorescein angiographic images of 61 eyes were assessed. Parameters studied for NVD were their number and location and for NVE were their number, location, type of leak, and distance from center of optic disc. Results Of 61 eyes, 29 eyes (47.5%) had NVD with a total of 49 leaks. Of these 49 NVD leaks, the maximum was concentrated in the superotemporal quadrant with 21 leaks (42.9%; 95%CI 28.8–57.8%). Of 61 eyes, 50 eyes (82%) had NVE with 97 leaks. Of 97 NVE leaks, 41 were found in the superotemporal quadrant (42.3%; 95%CI 32.3–52.7%). Maximum NVE was found within the circle of radius 3–6 mm centered on optic disc (p value = 0.001) with no leaks in central macula. Of 29 eyes with NVD, only 7 eyes had >1/3 area of disc involvement. Also, of 18 eyes with concurrent NVD and NVE, only 2 eyes had >1/3 area of disc involvement which is a high-risk characteristic of PDR. Conclusion Neovascular lesions have a predilection for superotemporal part for both NVD and NVE. NVE leaks were almost double the number of NVD leaks. Maximum NVE leaks were found at posterior pole with no central macular involvement. This study provides comprehensive data and further adds to knowledge of neovascularization for early diagnosis and management of PDR.

Background Surgical staging in endometrial cancer includes a systematic lymphadenectomy with significant morbidity, although its therapeutic role is unclear. Sentinel lymph node (SLN) study is a less morbid alternative to identify nodes most likely to be metastatic, permitting selective removal and thus reducing morbidity without compromising oncological safety. This study was done using blue dye single labelling to study the feasibility and utility in identifying SLN in early disease. Methods Twenty-two patients of early-stage low-risk disease during surgical staging underwent cervical injection of methylene blue, SLN mapping, and sampling as per the standard algorithm, followed by a systematic lymphadenectomy in all cases. SLN were submitted separately for ultrastaging (US). Results Twenty patients underwent the procedure, and SLN could be identified in 18 patients with an overall mapping rate of 90% with a bilateral mapping rate of 70%, and a negative mapping rate of 10%. 57 SLN were identified along with two suspicious non-sentinel nodes and 11 were metastatic on US with a sensitivity of 66.7% and NPV of 87.5%. All patients with metastatic nodes, however, could be identified by applying the standard SLN algorithm for sampling. Conclusion SLN mapping algorithm with blue dye single labelling in early endometrial cancer, by identifying LN most likely to be metastatic enabling their selective removal may help avoid routine lymphadenectomies without compromising oncological safety. The procedure is simple and can be practiced at all centres and can also aid pathologists by pinpointing the likely metastatic nodes after a selective or complete lymphadenectomy.

Background Emerging epidemiological evidence suggests that compared to engaging in 1 activity mode alone, a combination of moderate-to-vigorous physical activity (MVPA: brisk walking/jogging, cycling) and muscle-strengthening exercise (MSE: push-ups/sit-ups, using weight machines) has more favorable associations with optimal weight status. However, few studies have examined the dose-dependent and joint associations of MVPA and MSE with obesity. Methods Based on cross-sectional analyses of the European Health Interview Survey Wave 2 (2013–2014), we examined prevalence ratios (PRs) of joint and stratified associations between MVPA (4 categories: (i) 0 min/week, (ii) 1–149 min/week, (iii) 150–299 min/week, and (iv) ≥300 min/week) and MSE (3 categories: (i) 0 day/week, (ii) 1 day/week, and (iii) ≥2 days/week) with body mass index-defined obesity (body mass index of ≥30.0 kg/m2) using Poisson regression with robust error variance. PRs were examined unadjusted and adjusted for sociodemographic and lifestyle characteristics (e.g., sex, age, education, income, and smoking status). Results Data were available for 280,456 adults (≥18 years), of which 46,166 (15.5%) were obese. The interaction MVPA × MSE guideline adherence was statistically significant for obesity (p ≤ 0.05). The joint MVPA–MSE analysis showed that compared to the reference group (i.e., no MVPA and no MSE), the PRs followed a dose-dependent pattern, with the lowest observed among those reporting ≥150 MVPA min/week and ≥1 MSE days/week (PR: 0.43; 95% confidence interval: 0.41–0.46). When stratified across each MVPA strata, the PRs were mostly lower among those engaging in MSE 1 day/week, as compared to those doing MSE ≥2 days/week. Conclusion There was evidence for a dose-dependent association between joint MVPA–MSE with a reduced prevalence of obesity. Public health strategies for the prevention and management of obesity should recommend both MVPA and MSE.

Background Neonates at risk of hypoglycemia are often roomed in with mothers, but there is paucity of literature on the occurrence of hypoglycemia in these exclusively breastfed high-risk neonates. The primary objective was to estimate the incidence of hypoglycaemia in high-risk neonates on exclusive breastfeeding. The secondary objectives were to study the time of presentation, symptoms of hypoglycaemia, and the various maternal and neonatal risk factors. Methods This prospective observational study was carried out in a tertiary care teaching hospital of eastern India between January 2017 and June 2018. All neonates roomed in with mothers with high-risk factors such as low birth weight, preterm, small for gestational age, large for gestational age and infants of diabetic mothers were included. All included neonates were exclusive breastfed and underwent blood glucose monitoring at 2, 6, 12, 24, 48 and 72 h of life using glucometer strips and also whenever clinical features suggested hypoglycaemia. Hypoglycemia was defined as the blood glucose level ≤46 mg/dL. Results Of a total of 250 neonates studied, 52 (20.8%) developed hypoglycaemia in first 72 h. Hypoglycaemia was detected in most at 2 h with the second peak at 48 h of age. Only 8 (3.2%) neonates had symptomatic hypoglycaemia with jitteriness being the commonest symptom, followed by lethargy and poor feeding. Conclusion There is a need to closely monitor the blood glucose levels for at least first 48 h in high-risk neonates roomed in with mothers on exclusive breastfeeding.

Anaemia is a common complication of chronic kidney disease. The most important contributory factor is an abnormally low circulating concentration of erythropoietin, which is produced by the kidney peritubular cells. Anaemia of kidney disease is likely to develop once the glomerular filtration rate (GFR) is

Background Obesity is a chronic condition, affecting central and peripheral nervous system. Studies on cranial nerve conduction in obesity are scarce and unclear; therefore, we planned this study. The aim of this study was to evaluate optic and auditory nerve conductions in obesity. Methods It was a case-control study, with inclusion of 40 young males (20 obese and 20 controls) in age group of 18–30 years. We recorded pattern reversal visual evoked potential (PRVEP) and brainstem auditory evoked potential (BAEP). The PRVEP P100 latency and BAEP absolute and interpeak latencies were analyzed. Results In obese individuals, BAEP absolute latencies of wave V were significantly prolonged in both the ears and wave I in left ear. In addition, significant prolongation of interpeak latency III–V was observed in both the ears and I–V latency, in right ear among obese cases. A positive correlation was seen between body mass index and interpeak latency I–V. In PRVEP recordings, P100 latency did not show any significant difference in both the groups. Conclusion Therefore, we can conclude that obesity does not affect optic nerve conduction, but auditory nerve conduction is affected. BAEP I–V interpeak latency may be an indicator of subclinical auditory conduction defects in young obese males.

Background Impact of immeasurable time bias (IMTB) is yet to be examined in self-controlled designs. Methods We conducted case-crossover, case-time-control, and case-case-time-control analyses using Korea's healthcare database. Two empirical examples among elderly patients were used: 1) benzodiazepines-hip fracture; 2) benzodiazepines-mortality. For cases, the date of hip fracture diagnosis or death was defined as the index date, and the inherited date of their matched cases for controls or future cases. Exposure was assessed in the 1-30 day (hazard) and 61-90 day (control) windows preceding the index date. A non-missing exposure setting included in- and outpatient prescriptions and the pseudo-outpatient setting included only the outpatients. Conditional logistic regression was done to estimate odds ratio (OR) with 95% confidence intervals (CI), where the relative difference in OR among the two settings was calculated to quantify the IMTB. Results The IMTB had negligible impacts in the hip fracture example in the case-crossover (non-missing exposure setting OR 1.27, 95% CI 1.12-1.44; pseudo-outpatient setting 1.21, 1.06-1.39; magnitude 0.05), case-time-control (1.18, 0.98-1.44; 1.13, 0.92-1.38; 0.04), and case-case-time-control analyses (0.99, 0.80-1.23; 0.94, 0.75-1.18; 0.05). In the mortality example, IMTB had significant impacts in the case-crossover (1.44, 1.36-1.52; 0.72, 0.67-0.78; 1.00), case-time-control (1.38, 1.26-1.51; 0.68, 0.61-0.76; 1.03), and case-case-time-control analyses (1.27, 1.15-1.40; 0.62, 0.55-0.69; 1.05). Conclusions Although IMTB had negligible impacts on the drug's effect on acute events as these are unlikely to be accompanied with hospitalizations, it negatively biased the drug's effect on mortality, an outcome with prodromal phases, in the three self-controlled designs.

Abstract. As a follow-up to an earlier study demonstrating healthier cardiometabolic profiles among long-term multiple dietary supplement (LTMDS) users, we examined if cardiometabolic health benefits associated with LTMDS use persisted with aging. The study is based on LTMDS users from North America and 2007–2010 NHANES participants who were used for comparison to the LTMDS users. NHANES subjects were classified as non-dietary supplement (NS) users, single supplement/single purpose supplement (SS) users, multivitamin/mineral supplement (MVMS) users, and multiple dietary supplement (MDS) users. Supplement groups were compared for total, HDL and LDL cholesterol; triglycerides; glucose; insulin; CRP and HbA1c ≥ 6.5%, adjusting for age, sex, income, education, BMI, history of CVD, and medications for hypercholesterolemia and diabetes. Geometric mean (95% confidence interval) LDL cholesterol was significantly lower (P

Abstract. Purpose: Teas are an essential part of traditional phytotherapy. The aim of this systematic review is to assess the clinical evidence using green tea catechins in cancer care. Methods: A systematic search was conducted searching five electronic databases concerning the effectiveness and risks of epigallocatechin gallate (EGCG) on cancer patients. Results: Seven studies with 371 patients were included. Patients were mainly suffering from breast and prostate cancer. Dosing ranged from 28 mg to 1600 mg EGCG, intervention time from 7 days to 6 months with different applications (topical 2 studies; oral 5 studies). The studies showed heterogeneous methodological quality and results leading not to conduct a meta-analysis. There was a small decrease in prostate-specific-antigen levels in one study (N=60; T0:(mean±SD) 9.6±5.2 ng/ml, T1: 8.4±4.3 ng/ml vs. T0: 9.9±8.5 ng/ml, T1: 10.0±9.0 ng/ml; p=0.04), whereas in a second study only a trend was seen. Topical green tea was as effective as metronidazole powder in reducing the odor of fungating malignant wounds (1 study; N=30) with a consequent increase in quality of life (QoL) (p

The ability to correctly choose a suture material, appropriately suture a wound and ligate a structure are fundamental in any surgical speciality. These are index skills that a junior surgeon must master before progressing on to more complex procedures. This article discusses factors to consider when choosing suture material, techniques for closure of a wound, and knots used to ligate a structure. With use of minimally invasive techniques now widespread, the article also discusses laparoscopic methods for performing such tasks.

The recognition of cardiogenic shock in the setting of myocardial ischaemia has important prognostic and therapeutic implications. Resuscitative efforts should focus on stabilizing circulatory and respiratory function, with early restoration of coronary blood flow to avoid multi-organ dysfunction and death. However, despite recent progress, the mortality rate remains high, in the order of 40–50%. This article highlights several key recent advances in the management of ischaemic cardiogenic shock, including the use of early bedside echocardiography to confirm the diagnosis, and culprit only lesion strategies of early revascularization. Furthermore, we appraise the variety of mechanical cardiac supports that are increasingly being used to assist the management of ischaemic cardiogenic shock in those cases refractory to pharmacological intervention.

BACKROUND AND OBJECTIVE: Grip and knee strength are commonly measured but controversy exists as to whether either is a proxy for the other. The purpose of this meta-analysis was to summarize the correlation between the 2 variables. METHODS: Relevant literature was sought using PubMed, Google, and a hand search. Information on populations, measurements, and correlations were extracted. Correlational data were subjected to meta-analysis. RESULTS: Results from 17 studies were consolidated. The summary correlation between grip and knee extension strength was 0.64 with 95% CI of 0.57 to 0.71. Data were highly heterogeneous but did not show publication bias. CONCLUSION: The correlation between the grip and knee extension strength is good. However, it is not good enough to justify using either as a proxy for the other.

The COVId19 pandemic is a newly emerging infectious disease that needs to be understood thoroughly in order to be controlled. This study aimed to study the clinical and laboratory characteristics of the COVID19 patient . Patient and methods: A cross-sectional study was done in Iraq, at Salahadeen general hospital from the period 1st March to the end of May 2020 on patients diagnosed with COVID 19. A total of 75 COVID19 patients enrolled in the study. a full history was taken, a full physical examination was done, computerized tomography, and laboratory tests. Results: The age distribution of the COVID19 patient were commonly aged (30-50 years) 37(49.3%), and those aged

Polycystic ovary syndrome is a common cause of an ovulatory infertility. Drugs like Aromatase inhibitors, Human menopausal gonadotropin, used for ovulation induction. The aim of this study was carried out to compare the therapeutic effects of gonadotropin hormone versus oral ovarian stimulating agents. A prospective randomized controlled clinical trial was carried out in the Salahdeen general hospital in Tikrit from 1st Feb-30th August 2020. About 75 PCOs patients enrolled randomly in the study and divided equally into 3 groups as below: Group A treated with (75 IU intramuscular HMG gonadotropin) daily for 5 days starting Day 2 of menstrual cycle. Group B treated with oral clomiphene citrate 100 mg daily for 5 days starting Day 2 of menstrual cycle. Group C treated with oral Letrezole 5 mg daily for 5 days starting Day 2 of menstrual cycle. Multiple mature follicles were obtained commonly by HMG, followed by Letrozole, then Clomiphene, this relation was statistically significant. Endometrial thickness was higher among those treated with HMG (10.5±1.7) than those treated by Clomiphene (9.03±0.9), and then treated by letrozole (8.5±1.2). This is a significant difference in ET value between Clomiphene, letrozole, and HMG. Chemical pregnancy (early pregnancy loss that occurs shortly after implantation may account to 50-75% of all miscarriages) was higher among those treated with HMG (20%), while it was (16%) of those treated with Clomiphene, and (12%) of the Letrozole group, this relation was statistically not significant. In conclusion, HMG had the highest response rate, followed by Letrozole, and Clomiphene. The multiple mature follicles was obtained commonly by HMG, followed by Letrozole, then Clomiphene .

Studies of Doppler flow velocimetry have been proceeding as a principal mechanism for identification the compromised small fetus from a small fetus that is improbable to suffer from dangerous perinatal complications. The aim of this study is the Prediction of Perinatal Outcome in Fetuses Suspected to Have Intrauterine Growth Restriction: Doppler US Study of Fetal Cerebral, and Umbilical Arteries. This is a longitudinal prospective study done at department of Obstetrics and Gynecology in Salah Al-Deen General Hospital in Tikrit city between February-July 2020. The study included a convenient sample 100 pregnant women in 3rd trimester suspected of IUGR (n=100). Studies of various fetal vessels were performed using color Doppler ultrasound curvilinear probe with a high pass filter. The following vessels were studied with the mother in a recumbent position during fetal inactivity and apnea. 1st Umbilical Artery (UA), 2nd Middle Cerebral Artery (MCA). Fetal outcome was studied under major and minor adverse outcomes. The current study found that the umbilical artery systolic/diastolic ratio was concordant with major and minor adverse outcome among 55 cases regarding of abnormal finding, and among 25 cases regarding negative findings. The umbilical artery RI was concordant with major and/or minor adverse outcome among 34 cases regarding of abnormal finding, and among 28 cases regarding negative findings. The umbilical artery PI was concordant with major and/or minor adverse outcome among 52 cases regarding of abnormal finding, and among 29 cases regarding negative findings. Serial Doppler examinations of fetal (S/D ratio, UA RI, & UA PI), and (MCA PI, & MCA/UA PI) provide better information than does a single measurement.

BACKGROUND Helicobacter pylori (H. pylori) is an established causative factor of gastric cancer. Although the expansion of insurance coverage has led to an increase in the number of patients treated for H. pylori, the population impact of eradication treatment for H.pylori has been scarcely investigated. This study aimed to clarify the long-term responses of H. pylori antibody titer after eradication treatment using large scale cross-sectional data from the Japan Public Health Center-based Prospective Study for the Next Generation (JPHC-NEXT Study). METHODS A total of 55,282 Japanese participants aged 40 to 74 years residing in 16 areas provided blood samples between 2011 and 2016. From these, treated (n=6,276) and untreated subjects who were seropositive for H. pylori or had serological atrophy (n= 22,420) formed the study population (n=28,696). Seropositivity was defined as an anti-H. pylori IgG titer of ≥10 U/mL. Antibody level was compared among subjects according to self-reported treatment history as untreated, and treated for less than one year (

Introduction: patients with HIV/AIDS in developing countries have to face discrimination in the society and in health care system .The knowledge of people in such countries also not good enough as many of them don’t know the main information about this disease and some of them get infected because of lack of information Objective: To examine the knowledge of people about HIV/AIDS in Kirkuk city among different educational background. Subjects and Methods: A structured questionnaire form related to HIV/AIDS was administrated on the 6000 person included (primary, secondary, high school, university student and employers as well as public people). The questionnaire form included demographic items including gender, age, setting, and educational level and questions on AIDS related knowledge covering main topics. The data was analysed and evaluated by chi-square and student t-test. Result: The results of this study showed that the rate of knowledge about HIV/AIDS regarding the knowledge of people about the causative agent the highest knowledge was virus (80.86%) followed by bacteria (8.9%), parasite (3.38%), fungus (2.23%). the rate of knowledge about HIV/AIDS according to being zoonosis in females (32.1%) was higher than males (21.18%). The knowledge of university student (45.13%) was highest followed by high school (28%), secondary school (19.75%), and the primary school (8.68%). The knowledge of people about the prevention and control of the disease, the rate of correct answer (66.8%) was higher than incorrect one (28.9%). Conclusion: There is a gap in the existing knowledge of HIV/AIDS regarding route of transmission, causative agent, and general appearance of the disease.

Background This is the first randomized controlled trial of trabeculectomy with Ex-Press Shunt versus Ologen implant in primary open-angle glaucoma (POAG) in Indian eyes. Methods A prospective randomized controlled trial of patients of POAG treated with two different methods of augmented trabeculectomy. Group A with Ex-PRESS shunt (P50 model) and Group B with Ologen implant. Surgical success was defined as intraocular pressure of 21 mm Hg or lower at 6 months postoperative. Results N = 40 eyes of 33 patients. Baseline IOP in Group A was 23.70 ± 4.6 mm Hg (Range 22–36 mm Hg), and Group B was 26.00 ± 4.0 mm Hg (Range 23–36 mm Hg). Surgical success was achieved in 85% of patients in both Groups. Change in IOP from baseline was statistically significant in both groups at 1, 4, 8, 12 weeks, and 6 months postoperative. No statistically significant difference in the change in IOP between the two groups. Postoperative complications were lesser in Group A compared to Group B, in both early (35% vs 50%) and late stage (20% vs 30%). The drop in visual acuity became statistically insignificant at 4 weeks in Group A and 8 weeks in Group B. Conclusions There is no difference between the surgical success rates of trabeculectomy with Ex-PRESS Shunt versus Ologen. However, the Ex-PRESS shunt fares better with lower complication rates and faster visual recovery than the Ologen group.