Search

Mixed pancreatic epithelial and mesenchymal tumors are rare, usually invasive, entities. Intraductal papillary mucinous neoplasm (IPMN) is a precursor of invasive ductal carcinoma and shares mutations with its invasive counterparts. We report the case of a 72-year-old female with a previously undescribed sarcomatous transformation of a residual IPMN with no evidence of an invasive component. The mesenchymal component showed no heterologous differentiation. Both the epithelial and the mesenchymal populations showed aberrant expression of p53 protein and the same point mutation in KRAS gene. After a 6 month follow up, there were no signs of local or distant relapse. The present case suggests that sarcomatous transformation is possible in non-invasive, intraductal pancreatic lesions.

Purpose: This study aimed to evaluate the time interval to menarche after gonadotropin-releasing hormone agonist (GnRHa) treatment in females with central precocious puberty (CPP) and to identify factors contributing to timing of menarche.Methods: We retrospectively reviewed medical records of 39 females with CPP who reached menarche after GnRHa treatment (leuprolide or histrelin). CPP diagnostic criteria were breast development at

We studied clinical and immunological outcome of Covid-19 in consecutive CLL patients from a well-defined area during month 1–13 of the pandemic. Sixty patients (median age 71 y, range 43–97) were identified. Median CIRS was eight (4–20). Patients had indolent CLL (n = 38), had completed (n = 12) or ongoing therapy (n = 10). Forty-six patients (77%) were hospitalized due to severe Covid-19 and 11 were admitted to ICU. Severe Covid-19 was equally distributed across subgroups irrespective of age, gender, BMI, CLL status except CIRS (p

A newly distributed fault-tolerant mHealth framework-based Internet of things (IoT) is proposed in this study to resolve the essential problems of healthcare service provision during the occurrence of frequent failures in a telemedicine architecture. Two models are presented to support the telehealth development of chronic heart disease (CHD) in a distant environment. In model-1, a new local multisensor fusion triage algorithm known as three-level localisation triage (3LLT) is proposed. In 3LLT, a group of heterogeneous sources is applied to triage patients as a clinical process, and the emergency levels inside/outside the home of a patient with CHD are determined. Failures related to sensor fusion can also be detected. In model-2, a centralised IoT connection towards distributed smart hospitals is employed by mHealth based on two attributes: (1) healthcare service packages and (2) time of arrival of a patient at a hospital. Three decision matrices have been used to overcome several issues on hospital selection based on multi-criteria decision-making by using an analytic hierarchy process. Two datasets are utilised: (1) a clinical CHD dataset, which includes 572 patients for testing model-1, and (2) a nonclinical dataset, which includes hospital healthcare service packages for testing model-2. Consequently, patients with CHD can be triaged into different emergency levels (risk, urgent and sick) with mHealth, and a final decision is made by selecting an appropriate hospital. Results are obtained through the clinical triage of patients, and different scenarios are provided for hospital selection. The verification of statistical results indicates that the proposed mHealth framework is systematically valid. The contribution of the mHealth framework is presented to provide an improved triage process, afford timely services and treatment for CVD patients and minimise the chances of error. These health sectors and policymakers can also recognise the evaluation benefits of smart hospitals by using the presented framework and move forward to fully automated mHealth applications.

Eating outside the three main meals - in other words, snacking - is a part of the dietary pattern of individuals in all stages of life. The quality and pattern of snacking have an impact on health during the life span. Thus, the aim of this review was to evaluate various patterns and health outcomes of the snacking habits of different demographical groups, from children to the elderly, throughout their life span. We discuss the snacking pattern among children and adolescents, which is characterized by consuming high energy foods with low nutrient value, and which is associated with increased risk of obesity. During university years, study stress and lack of time were obstacles to a healthy dietary pattern involving nutritious snacks, although awareness of the importance of healthy snacks was higher in this group than among younger age groups. Employment status and skipping regular meals were important factors affecting snacking quality and patterns in adulthood. Unhealthy snacks, high in energy, sugar, and salt and low in nutrients, were demonstrated to have a negative impact on individuals' health, such as oral health, blood pressure, obesity, and diabetes. In conclusion, encouraging individuals to consume healthy snacks that are high in nutrients through education to help them plan for their snacks is important to enhance health and reduce disease risk.

Purpose: This work aims to present treatment and long-term follow-up of a 31-year-old woman with dermatomyositis who presented with hemorrhagic retinal vasculitis and macular edema. Methods: A retrospective case report is presented. Results: A 31-year-old woman with dermatomyositis treated with systemic immunosuppression was evaluated for acute, reduced vision. Best-corrected visual acuity was hand motion in the right eye and 20/200 in the left eye. Fundus examination revealed diffuse intraretinal hemorrhages, cotton-wool spots, and vascular sheathing with a frosted branch angiitis–like appearance. Optical coherence tomography revealed significant macular edema and subretinal fluid that quickly resolved after admission and treatment with intravenous steroids. Multimodal imaging at 7-year follow-up disclosed long-term sequelae including peripheral nonperfusion and retinal neovascularization. Conclusions: When vasculitis associated with dermatomyositis is treated aggressively with intravenous steroids at initial presentation, good visual acuity outcomes can be achieved, but long-term consequences of retinal nonperfusion and neovascularization persist.

Introduction: Anti-glomerular basement membrane (anti-GBM) disease is characterized by rapidly progressive glomerular nephritis with or without pulmonary hemorrhage with disease severity correlating with antibody titer. Following treatment, relapse is rare but has been reported in the literature. The objective of this study was to assess for clinical, serologic, and histologic differences associated with disease relapse in patients with anti-GBM disease. Methods: Patients seen at our facility between 1997 and 2017 were screened for anti-GBM disease by ICD 9/10 codes. They were included if the diagnosis was confirmed by a board-certified rheumatologist or nephrologist and had positive antibodies and/or biopsy results consistent with anti-GBM disease. Relapsing disease was defined as recurrence of pulmonary or renal manifestations after achieving remission following the initial presentation. All charts were reviewed for baseline demographics, clinical manifestations, and antibody positivity and compared between groups. Results: 40 patients were confirmed as having anti-GBM disease. Mean follow-up from disease onset to the date of last follow-up was 56.2 months. 8 patients had relapsing disease and 32 patients had nonrelapsing disease. Baseline characteristics and clinical manifestations were similar between groups. Patients with relapsing disease had a high incidence of anti-neutrophilic cytoplasmic antibody (ANCA) co-positivity as compared to nonrelapsing patients (50 vs. 15.6%, respectively, p = 0.059), but this did not reach statistical significance. In patients with relapsing disease, only one had positive anti-GBM antibodies at time of relapse. Conclusions: In this study, patients with relapsing disease had a high incidence of ANCA co-positivity (50%). In patients with newly diagnosed anti-GBM disease, ANCAs should be obtained to assess for the risk of relapse and to help guide long-term follow-up and treatment.

BACKGROUND AND PURPOSE: Lumbar punctures may be performed by many different types of health care providers. We evaluated the percentages of lumbar punctures performed by radiologists-versus-nonradiologist providers, including changes with time and discrepancies between specialties. MATERIALS AND METHODS: Lumbar puncture procedure claims were identified in a 5% sample of Medicare beneficiaries from 2004 to 2017 and classified by provider specialty, site of service, day of week, and patient complexity. Compound annual growth rates for 2004 versus 2017 were calculated; t test and χ(2) statistical analyses were performed. RESULTS: Lumbar puncture use increased from 163.3 to 203.4 procedures per 100,000 Medicare beneficiaries from 2004 to 2017 (overall rate, 190.3). Concurrently, the percentage of lumbar punctures performed by radiologists increased from 37.1% to 54.0%, while proportions performed by other major physician specialty groups either declined (eg, neurologists from 23.5% to 10.0%) or were largely unchanged. While radiologists saw the largest absolute increase in the percentage of procedures, the largest relative increase occurred for nonphysician providers (4.2% in 2004 to 7.5% in 2017; +78.6%). In 2017, radiologists performed most procedures on weekdays (56.2%) and a plurality on weekends (38.2%). Comorbidity was slightly higher in patients undergoing lumbar puncture by radiologists (P < .001). CONCLUSIONS: Radiologists now perform most lumbar puncture procedures for Medicare beneficiaries in both the inpatient and outpatient settings. The continuing shift in lumbar puncture responsibility from other specialists to radiologists has implications for clinical workflows, cost, radiation exposure, and postgraduate training.

We studied whether mood and demographics are related to body mass index in a population of Syrian and Iraqi refugees residing in Jordan. Questionnaires and Brunel Mood Scale were used to collect demographical data. Data were analyzed using t-test and analysis of variance. A high prevalence of overweight and obesity was observed in this population (60.5%). Mood subscales were not associated with body mass index categories. However, body mass index as a continuous variable was associated with anger, depression, and fatigue scores. Linear regression revealed that age, ethnicity, unemployment, chronic illnesses, and physical activity level, but not mood, are associated with body mass index.

There are currently no reliable epidemiological data for estimating the burden of sexually transmitted infections (STIs) in Oman. STIs such as gonorrhoea and chlamydia are often asymptomatic and associated with sexual and reproductive morbidity. An exploratory study was conducted in an antenatal clinic in Muscat, Oman, to assess the acceptability and feasibility of testing for gonorrhoea and chlamydia. Two hundred and twenty-one women were recruited over 14 weeks between July and October 2020. There were three cases of chlamydia (3/221, 1.36%); no cases of gonorrhoea were identified. Acceptability and feasibility for testing in this cohort of pregnant women were good despite anticipated cultural sensitivities surrounding sexually transmitted infections.

HPV vaccination rates have improved in recent years, but remain suboptimal in the United States. Physician recommendation is associated with increased uptake; however, specific strategies used by physicians to recommend the vaccine and address hesitancy are underexplored. We iteratively conducted qualitative in-depth interviews with family medicine and pediatrics/adolescent medicine physicians recruited from four primary care settings (federally qualified health centers and hospital-affiliated practices) within a large academic-hospital system in New Jersey. Interviews aimed to understand factors influencing physician recommendations. Transcripts were analyzed iteratively using a team-based, thematic content analysis approach. All physicians reported strong support for HPV vaccination, intention to recommend for target age groups, and providing factsheets to parents. Many physicians used electronic medical records and/or the state immunization registry for monitoring vaccinations, but few were able to report their own clinic-level rates. The majority said they needed to overcome both hesitancy for at least 10–30% of parents and misinformation from the internet. Most cited having their own children vaccinated for HPV as a first-line strategy for addressing parental hesitancy. Other strategies included using data or professional authority to address safety concerns, linking HPV to cervical cancer, highlighting only needing two doses if vaccinated younger, and normalizing the vaccine. While our findings indicate physicians are knowledgeable about HPV vaccination and recommend it to parents, strategies to overcome parental hesitancy varied. Physician, clinic, and health-system-based strategies need to be adopted to overcome parental hesitancy for HPV vaccination.

Purpose This study has been conducted to identify the rate of varicocele recurrence in patients who underwent microscopic subinguinal varicocelectomy at our center. We also aimed to determine the contributing factors to varicocele recurrence. Patients and methods A total of 34 married male patients who underwent microscopic sub-inguinal varicocelectomy were retrospectively included in this study. The medical records of recruited patients were reviewed. The diagnosis of varicocele was based on physical examination, while recurrent varicocele was diagnosed based on both physical examination and colored doppler ultrasound. We investigated contributing factors to varicocele recurrence, including demographic characteristics (such as body mass index), clinical (varicocele grade and size of dilated veins), and laboratory data (semen analysis). Patients were followed up at 3 and 6 months after surgery. Results The mean age of patients was 32.53 years. The majority of patients had left-sided varicocele (70.6%) and underwent surgery due to scrotal pain (82.4%), with a mean operation duration of 92 minutes. Left-sided varicoceles were grade II in 51.7% of patients, while right-sided varicoceles were grade II in 16.1% of patients. Recurrence occurred in 2.9% after 3 and 6 months. Pain recurred in 8.8% and 10.5% of patients at 3 and 6 months, respectively. Pregnancy rates were 44.1% at 3 months and 11.8% at 6 months after surgery. The grade of varicocele (P = 0.24) and the size of the left dilated vein (P = 0.002) was significantly associated with recurrence. Conclusion There was a significant association of advanced grade on the left side and large vein diameter before and after surgery with an increased rate of recurrence; however, due to the small sample size of our study, more and larger studies are still warranted.

Background Current standard practice for locally advanced rectal cancer (LARC) entails a multidisciplinary approach that includes preoperative chemoradiotherapy, followed by total mesorectal excision, and then adjuvant chemotherapy. The latter has been accompanied by low compliance rates and no survival benefit in phase III randomized trials, so the strategy of administering neoadjuvant, rather than adjuvant, chemotherapy has been adapted by many trials, with improvement in pathologic complete response. Induction chemotherapy with oxaliplatin has been shown to have increased efficacy in rectal cancer, while short-course radiation therapy with consolidation chemotherapy increased short-term overall survival rate and decreased toxicity levels, making it cheaper and more convenient than long-course radiation therapy. This led to recognition of total neoadjuvant therapy as a valid treatment approach in many guidelines despite limited available survival data. With the upregulation (PDL-1) expression in rectal tumors after radiotherapy and the increased use of in malignant melanoma, the novel approach of combining immunotherapy with chemotherapy after radiation may have a role in further increasing pCR and improving overall outcomes in rectal cancer. Methods The study is an open label single arm multi- center phase II trial. Forty-four recruited LARC patients will receive 5Gy x 5fractions of SCRT, followed by 6 cycles of mFOLFOX-6 plus avelumab, before TME is performed. The hypothesis is that the addition of avelumab to mFOLFOX-6, administered following SCRT, will improve pCR and overall outcomes. The primary outcome measure is the proportion of patients who achieve a pCR, defined as no viable tumor cells on the excised specimen. Secondary objectives are to evaluate 3-year progression-free survival, tumor response to treatment (tumor regression grades 0 & 1), density of tumor-infiltrating lymphocytes, correlation of baseline Immunoscore with pCR rates and changes in PD-L1 expression. Discussion Recent studies show an increase in PD-L1 expression and density of CD8+ TILs after CRT in rectal cancer patients, implying a potential role for combinatory strategies using PD-L1- and programmed-death- 1 inhibiting drugs. We aim through this study to evaluate pCR following SCRT, followed by mFOLFOX-6 with avelumab, and then TME procedure in patients with LARC. Trial registration Trial Registration Number and Date of Registration: ClinicalTrials.gov NCT03503630, April 20, 2018.

Breast conservation surgery (BCS) aims to excise all cancerous tissue while minimizing the amount of healthy breast tissue removed. Up to 30% of patients undergoing BCS require a second operation for re-excision to obtain negative margins. Previous studies reported a lower re-excision rate with intraoperative use of the MarginProbe device (Dune Medical Devices). This device utilizes radiofrequency spectroscopy to detect differences between cancerous and normal tissue. From July 2009 to January 2010, our institution enrolled 46 patients electing for BCS in a prospective double-arm randomized controlled trial and had a significantly lower re-excision rate than that reported in the multicenter trial. Intraoperatively, after performing conventional lumpectomy with excision of any additional shavings deemed necessary based on palpation and visual inspection alone, patients were then randomized. In the device arm, the surgeon used the MarginProbe to interrogate the lumpectomy specimen, taking additional shavings from the cavity surfaces corresponding to the parts of the specimen read as positive by the device. In the control arm, only standard intraoperative assessments were performed. All specimens were evaluated by pathologists who were blinded to the study arm. In this population, 72% had invasive ductal carcinoma (IDC), 20% had ductal carcinoma in situ (DCIS), and 8% had invasive lobular carcinoma (ILC). Average age was 64 years old. The average size of the specimen was 5.6 cm, the average volume was 37.8 cm3 , and the average weight was 32.7 g. The mean size of DCIS was 1.4 cm. For invasive specimens, 32 were T1 and 7 were T2. Prior to randomization, 43 patients were thought to have positive or close margins and therefore underwent additional shavings. Twenty-three patients were randomized to the device arm and 23 to the control arm. In the device arm, 14 (60%) patients had IDC, 7 (30%) had DCIS, and 2 (8%) had ILC, vs the control arm where 19 (82%) patients had IDC, 2 (8%) had DCIS, and 2 (8%) had ILC. Eight (35%) patients in the control group vs 1 (4%) in the device group underwent re-excision for margin involvement (P < .05). The use of the MarginProbe device at our institution significantly improved the ability of our surgeons to obtain clear margins during initial BCS. Our results show a lower re-excision rate (4%) than those published in the multicenter trial (19.8%). We postulate that in the face of more patients having DCIS in our device group (30%), our surgeons responded by taking thicker shavings when the MarginProbe device reported margin involvement during the initial lumpectomy, resulting in greater success achieving clear final margins on the shaved tissue and a significantly lower re-excision rate than previously reported with the MarginProbe device.

Background The low subject contrast between cancerous and fibroglandular tissue could obscure breast abnormalities. Purpose To investigate radiologists’ performance for detection of breast cancer in low and high mammographic density (MD) when cases are digitally acquired. Material and Methods A test set of 60 digital mammography cases, of which 20 were cancerous, were examined by 17 radiologists. Mammograms were categorized as low (≤50%) or high (>50%) MD and rated for suspicion of malignancy using the Royal Australian and New Zealand College of Radiology (RANZCR) classification system. Radiologist demographics including cases read per year, age, subspecialty, and years of reporting were recorded. Radiologist performance was analyzed by the following metrics: sensitivity; specificity; area under the receiver operating characteristic (ROC) curve (AUC), location sensitivity, and jackknife free-response ROC (JAFROC) figure of merit (FOM). Results Comparing high to low MD cases, radiologists showed a significantly higher sensitivity ( P = 0.015), AUC ( P = 0.003), location sensitivity ( P = 0.002), and JAFROC FOM ( P = 0.001). In high compared to low MD cases, radiologists with Conclusion In this experimental situation, radiologists’ performance was higher when reading cases with high compared to low MD. Experienced radiologists were able to precisely localize lesions in breasts with higher MD. Further studies in unselected screening materials are needed to verify the results.

The relationship between obesity and various chronic diseases is well documented. In Jordan, the prevalence of overweight (30.0%) and obesity (38.8%) among females is on the rise, encouraging many adults to rely on alternative health care methods to manage their weight.We explored the status of complementary and alternative medicine use for weight management among adult females in Jordan and the possible relationship between complementary and alternative medicine use and body mass index.An interviewer-administered, structured questionnaire was used to collect data on the use and safety of complementary and alternative medicine for weight management from 858 women in 2015. Responses were coded and analysed using SPSS, version 20.Around 40% of the respondents reported using some form of complementary and alternative medicine for weight management. Commercial dietary supplements (31.2%), herbal remedies (26.7%) and folk remedies (18.0%) were commonly used. Green tea and fibre tablets were the most widely used herbal supplements. Logistic regression analysis indicated that overweight participants are more frequent complementary and alternative medicine users compared to obese. Relatives and friends were the main sources of information about complementary and alternative medicine. Only 31.9% of women believed that complementary and alternative medicine modalities were safe; around half believed they were not safe during pregnancy (52.5%) and lactation (48.0%). Only 49.7% were aware of side-effects and 41.5% of drug interactions.This study revealed that complementary and alternative medicine is often used for weight management. Awareness of the safe use of complementary and alternative medicine with other medications and during pregnancy and lactation should be addressed.استخدام الطب التكميلي والبديل للتحكم بالوزن بين الإناث في الأردن: مسح مجتمعي.ميادة بشير شحادة، غدير اسعيفان، آلاء أبو عودة، رلى درويش.هناك توثيق جيد للعلاقة بين البدانة والإصابة بمختلف الأمراض المزمنة. وفي الأردن، يزداد معدل انتشار زيادة الوزن (%30.0) والبدانة (%38.8) بين الإناث على نحو مطرد، الأمر الذي دفع الكثير من البالغين إلى الاعتماد على وسائل الرعاية الصحية البديلة من أجل التحكم في أوزانهم.هدفت الدراسة إلى الكشف عن مدى وضع استخدام الطب التكميلي والبديل من أجل التحكم في الوزن بين الإناث البالغات في الأردن والعلاقة المحتملة بين استخدام الطب التكميلي والبديل ومؤشر كتلة الجسم.اسْتُخدم استبيان قائم على إجراء المقابلات بصورة منظمة من أجل جمع بيانات من 858 سيدة في عام 2015 حول استخدام الطب التكميلي والبديل ومأمونيته فيما يتعلق بالتحكم في الوزن. ورُمِّزت استجابات المشاركات وخضعت للتحليل باستخدام الإصدار 20 من برنامج SPSS.أبلغ %40 من المشاركات باستخدامهن نوعا من أنواع الطب التكميلي والبديل للتحكم في أوزانهن. وتبين شيوع استخدام المكملات الغذائية التجارية (%31.2)، والعلاجات العشبية (%26.7) والعلاجات الشعبية (%18.0). وكان الشاي الأخضر وأقراص الألياف هي الأكثر استخداما من بين المكملات العشبية الأخرى. وأوضح تحليل الانحدار اللوجستي أن المشاركات ذوات الوزن الزائد هن أكثر المستخدمات للطب التكميلي والبديل، مقارنة بالمشاركات البدينات. وكان الأقارب والأصدقاء هم المصدر الرئيسي للمعلومات بشأن الطب التكميلي والطب البديل. واعتقد %31.9 فقط من النساء أن الأساليب المتبعة في الطب التكميلي والطب البديل مأمونة؛ بينما اعتقد نحو نصف النساء أن تلك الأساليب غير مأمونة أثناء الحمل (%52.5) وأثناء الإرضاع (%48.0). وكان %49.7 فقط على وعي بالآثار الجانبية، و %41.5 على وعي بالتفاعلات الدوائية.كشفت هذه الدراسة عن استخدام الطب التكميلي والطب البديل في كثير من الأحيان بغرض التحكم في الوزن. ولذا، يتعين التصدي لإذكاء الوعي بالاستخدام الآمن للطب التكميلي والطب البديل مع الأدوية الأخرى وأثناء الحمل والإرضاع.Recours aux médecines complémentaires et alternatives dans le cadre de la gestion du poids chez les femmes en Jordanie : enquête communautaire.Le lien entre obésité et plusieurs maladies chroniques est clairement attesté. En Jordanie, la prévalence du surpoids (30,0 %) et de l’obésité (38,8 %) chez les femmes est en augmentation, incitant ainsi de nombreux adultes à se tourner vers les méthodes de soins alternatives en vue de gérer leur poids.La présente étude visait à examiner le statut du recours aux médecines complémentaires et alternatives (MCA) dans le cadre de la gestion du poids chez les femmes adultes en Jordanie et le lien possible entre cette pratique et l’indice de masse corporelle (IMC).Un questionnaire structuré, administré par un enquêteur, a été utilisé en 2015 auprès de 858 femmes pour recueillir des données sur l’utilisation et la sécurité des MCA en vue de la gestion du poids. Les données ont été codées et analysées à l’aide du logiciel SPSS, version 20.Près de 40 % des femmes interrogées indiquaient avoir recours à certaines formes de MCA en vue de gérer leur poids. Les suppléments alimentaires commercialisés (31,2 %), les remèdes à base de plantes (26,7 %) et les remèdes populaires (18,0 %) étaient couramment utilisés. Le thé vert et les comprimés de fibres étaient les compléments à base de plantes les plus largement utilisés. L’analyse de régression logistique indiquait que les participantes en surpoids recouraient plus fréquemment aux MCA que celles qui étaient obèses. En ce qui concerne les MCA, les proches et les amis constituaient les principales sources d’information. Seuls 31,9 % des femmes estimaient que les modalités du recours aux MCA étaient sûres ; près de la moitié pensaient que ces types de médecines n’étaient pas recommandées pendant la grossesse (52,5 %) et l’allaitement (48,0 %). Seulement 49,7 % avaient connaissance des effets secondaires et 41,5 % des interactions médicamenteuses.Cette étude a révélé que les MCA sont souvent utilisées dans la cadre de la gestion du poids. Il convient d’augmenter la sensibilisation à l’égard de cette pratique en association avec d’autres médicaments et pendant la grossesse et l’allaitement.

Introduction: The purpose of this study was to illustrate the potential costs and health consequences of implementing advanced CT angiography and perfusion (CTAP) as the initial imaging in patients presenting with acute ischemic stroke (AIS) symptoms at a comprehensive stroke center (CSC).Methods: A decision-simulation model based on the American Heart Association's recommendations for AIS care pathways was developed to assess imaging strategies for a 5-year period from the institutional perspective. The following strategies were compared: (1) advanced CTAP imaging: NCCT + CTA + CT perfusion at the time of presentation; (2) standard-of-care: non-contrast CT (NCCT) at the time of presentation, with CT angiography (CTA) ± CT perfusion only in select patients (initial imaging to exclude hemorrhage and extensive ischemia) for mechanical thrombectomy (MT) evaluation. Model parameters were defined with evidence-based data. Cost-consequence and sensitivity analyses were performed. The modified Rankin Scale (mRS) at 90 days was used as the outcome measure.Results: The decision-simulation modeling revealed that adoption of the advanced CTAP imaging increased per-patient imaging costs by 1.19% ($9.28/$779.72), increased per-patient treatment costs by 33.25% ($729.96/$2,195.24), and decreased other per-patient acute care costs by 0.7% (–$114.12/$16,285.85). The large increase in treatment costs was caused by higher proportion of patients being treated. However, improved outcomes lowered the other per-patient acute care costs. Over the five-year period, advanced CTAP imaging led to 1.63% (66/4,040) more patients with good outcomes (90-day mRS 0-2), 2.23% (66/2,960) fewer patients with poor outcomes (90-day mRS 3-5), and no change in mortality (90-day mRS 6). Our CT equipment utilization analysis showed that the demand for CT equipment in terms of scanner time (minutes) was 24% lower in the advanced CTAP imaging strategy compared to the standard-of-care strategy. The number of EVT procedures performed at the CSC may increase by 50%.Conclusions: Our study reveals that adoption of advanced CTAP imaging at presentation increases the demand for treatment of acute ischemic stroke patients as more patients are diagnosed within the treatment time window compared to standard-of-care imaging. Advanced imaging also leads to more patients with good functional outcomes and fewer patients with dependent functional status.

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by recurrent thunderclap headaches (TCH) and reversible segmental and multifocal vasoconstriction of cerebral arteries. Noninvasive neuroimaging such as computed tomography (CT), and magnetic resonance imaging (MRI) are widely used to assess cerebral vasculature, ischemic or hemorrhagic stroke, and posterior reversible encephalopathy (PRES). The significant differential diagnoses of RCVS center on the clinical presentation of headache and similar radiographic features including aneurysmal subarachnoid hemorrhage (SAH), cervical artery dissection, and central nervous system vasculitis (CNS-V). In this review we present a comprehensive overview of RCVS with the newest findings in the reported literature. Pathophysiology: Several surrogate markers including plasma endothelin-1 (E-1) have been investigated to elucidate the pathogenesis of RCVS. Clinical evaluation and diagnosis: The RCVS2 score is a simple scoring system has been proposed to distinguish RCVS from other intracranial vasculopathies. Neuroimaging: High-resolution contract-enhanced MRI (HR-MRI) vessel wall imaging is a feasible tool in differentiating vessel wall patterns of RCVS and CNS-V. Treatment: Early initiation of calcium channel blockers effectively prevents recurrent TCH and shorten the clinical courses. Clinical scoring system and newer imaging tools are helpful for the early distinction of RCVS. These approaches may serve increased sensitivity and specificity for the diagnosis and lead to appropriate management in RCVS patients.

Objective: In this study, while evaluating the effectiveness of splint, injection, paraffin and surgical treatment with Magnetic Resonance Imaging (MRI) in patients with idiopathic carpal tunnel syndrome (CTS), we investigated the consistency between MRI measurements performed by different observers.Material and Methods: Boston questionnaires were evaluated, and the cross-sectional areas (CSA) of the median nerve were measured by two different observers, in 50 hands of 50 patients with idiopathic CTS.Results: The CSA of the median nerve at the radiocarpal joint level of the canal were significantly larger than the values at the hamate level of the canal when values before treatment and three months after treatment were compared (p

Background: Noncommunicable diseases (NCDs) are among the most common medical problems encountered in medical practice worldwide. The World Health Organization package of essential NCD (WHO PEN) interventions is a broad framework for integration of major NCDs into primary health care. These interventions include screening of diseases and their risk factors to prevent complications. WHO supports the adoption of WHO PEN into the Palestine Ministry of Health. PEN has been implemented in Gaza district since 2015, but only the protocols for cardiovascular disease and diabetes were selected for implementation. This study may help us to detect the impact of implementing PEN. Methods: A retrospective record review study was conducted using a random sample of 143 files from a total of 280 registered NCD patients who were followed up for 2 years at Alsourani clinic. Data were extracted manually from the medical records with the completion of a data sheet. Results: The study showed that most of the population was female (n = 86, 60.1%). The mean age was 58.8 ± 11.7 years. The vast majority were living a sedentary lifestyle (n = 141, 98.6%). Patients with one or more comorbidities were also tabulated according to the presence of each comorbidity among all subjects: hypertension (n = 92, 64.3%), any diabetes (n = 90, 62.9%), type 2 diabetes (n = 86, 60.1%), type 1 diabetes (n = 4, 2.8%), dyslipidemia (n = 41, 28.7%), neuropathy (n = 27, 18.9%), ischemic heart disease (n = 20, 14%), cerebrovascular disease (n = 4, 2.8%), retinopathy (n = 8, 5.6%), mental illness (n = 4, 2.8%), nephropathy (n = 3, 2.1%), cancer (n = 2, 1.4%), and respiratory diseases (n = 1, 0.7%). There was no statistically significant difference between pre- and post-parameter interventions for systolic and diastolic blood pressure, waist circumference, weight, body mass index, and cholesterol, as well as for tobacco use and cardiovascular risk (p > 0.05). In contrast, fasting blood sugar was lower, with a statistically significant difference (p = 0.049). Conclusion: NCDs in Palestine are a major health problem. Sustainability of WHO PEN interventions is recommended with insurance to support the needs of NCD patients and home visits. NCD interventions are compromised due to health care system gaps at primary care level. Therefore, we need strengthening of the primary health care system.

Background In the occupied Palestinian territory (oPt), access to maternal and child healthcare (MCH) services are constrained due to the prolonged Israeli military occupation, the Separation Wall, army checkpoints, and restrictions on the movement of people and goods. This study assesses the relationship between conflict intensity and access to Maternal and Child Health care in occupied Palestinian territory (oPt). To the best of our knowledge, the impact of conflict on access to health care has not been measured due to the lack of data. Methods We analyse pooled data from household surveys covering a fifteen-year period (2000–2014) of children (n = 16,793) and women (n = 8477) in five regions of the oPt. Conflict intensity was used as a continuous variable defined as the square root of non-combatant conflict mortality taken from monthly death rates of non-combatants by region. We use multilevel logistic models to explain four outputs: child vaccination schedules, antenatal care, caesarean sections, and complications during pregnancy. Results Locality is important with results showing the negative impact of conflict intensity on access to care, especially in the South West Bank for maternal health services and Central West Bank for vaccination (B − 0.161 p = 0.000 for DPT). Wealth is only significant for DPT vaccinations with poorest (B − 0.098 p = 0.005) and poor (B − 0.148 p = 0.002) individuals less likely to access services. Otherwise conflict does not show a differential effect across socio-economic conditions. Conclusions This study shows how locality is the strongest factor when looking at the impact of conflict in the oPt. Preventative services (ANC and vaccinations) are the most affected by conflict. We recommend a greater use of community health care to improve access to maternal and child care when barriers impede access to health facilities during times of conflict.

Background. Takayasu’s arteritis with comorbid chronic recurrent multifocal osteomyelitis and ulcerative colitis is rare in the pediatric population. Treatment with anti-TNF alpha agents such as infliximab has been a successful treatment strategy in adults and can be used effectively in the pediatric population. Case Presentation. We present the case of a 15-year-old Caucasian girl with a history of chronic recurrent multifocal osteomyelitis and ulcerative colitis presenting with hypertensive emergency secondary to Takayasu’s arteritis with middle aortic syndrome. She was treated with corticosteroids and methotrexate and ultimately required infliximab infusions of 15 mg/kg every 4 weeks to successfully control her symptoms and normalize her inflammatory markers. Conclusions. In this case, we discuss the use of infliximab in an adolescent patient with chronic recurrent multifocal osteomyelitis, ulcerative colitis, and Takayasu’s arteritis. The significance of this case is determined by the unique occurrence of all three conditions in a pediatric patient, the important consideration of vasculitis in the differential of a pediatric patient presenting with hypertensive emergency, the need for vigilance for detecting diagnostic clues, signs, and symptoms, knowledge of disease associations when evaluating a patient with a predisposition for autoinflammatory conditions, and the use of increasing doses of infliximab to control symptoms.

Background: To identify stress associated factors for vitamin D deficiency (VDD) in healthy Jordanian people based on serum 25(OH)D levels. Design: Prospective cohort study. Methods: Three hundred and seventy-one Jordanian men and women aged 17-52 years, who were identified as VD deficient 25(OH)D

Objective The objectives were: 1) to explore the discordance between the Patient Global Health Assessment (PtGA) scores, the Physician Global Health Assessment (PhGA) scores, and Pain scores; and 2) to explore whether the PtGA during disease remission is associated with future disease flare in pJIA. Methods Data from an NIH funded clinical trial (NCT00792233) evaluating flare were used (N = 137). PtGA, PhGA, and Pain scores were assessed. Flare was defined as any active arthritis. Spearman’s correlation coefficients were calculated, and multivariable logistic regression was performed. Results 122 patients had records of flare status, of which 63 developed flare, and 42 of these patients had a visit immediately prior to flare. For study subjects with a visit immediately prior to flare, the PtGA, pain scores, and PhGA all increased at time of flare. For every unit increase in PtGA and Pain scores, there was a 9% and 23% higher odds of developing flare, respectively (p = 0.76, p = 0.40). For every unit increase in the PhGA score, there was a substantially lower odds of developing flare (p = 0.05). Conclusion Our results demonstrate that the PtGA and Pain scores are strongly correlated with each other and increased at the visit prior to flare, while the PhGA scores are not. Further, the PtGA and Pain score have some predictive value for flare, while the PhGA does not. These findings highlight the value of patient input in medical care and decision-making, and support the development and use of more sophisticated PROs in the care of JIA patients.

BackgroundVenous thromboembolic events (VTE) are commonly encountered in patients with lymphoma. Several risk assessments models (RAM) had attempted to identify higher risk patients with varying success. The International Prognostic Index (IPI) is a clinicopathological tool developed to help predict both response to treatment and prognosis of patients with diffuse large B-cell lymphoma (DLBCL).ObjectiveIn this study, we utilize the IPI index to identify group of patients with DLBCL at higher risk for VTE.Patients/MethodsPatients with pathologically-confirmed diagnosis of DLBCL and with image-confirmed VTE, treated and followed at our institution were included. Rates of VTE was calculated for each risk category.ResultsA total of 373 patients, median age 49 (range: 18-90) years were included. VTE were reported in 56 (15.0%) patients; 51 (91.1%) had active disease while 29 (51.8%) were ambulatory at time of VTE diagnosis. VTE rates were particularly high among patients with poor performance status (26.2%, P=0.028) and high LDH (19.0%, P=0.023). Applying the age-adjusted IPI separated patients into two risk categories; VTE were diagnosed in 9.7% in patients with “low and low-intermediate” scores compared to 19.8% in patients with “high and high-intermediate” scores, P=0.020.ConclusionsThe original IPI and its modified versions, routinely used at diagnosis as a prognostic and predictive tool for patients with DLBCL, can also be utilized to define high risk patients for VTE; the risk of whom might be high enough to recommend thromboprophylaxis even in the ambulatory settings. More work is needed to refine and improve currently available RAMs.

Haploidentical hematopoietic cell transplantation (HCT) is a valuable curative option for children with non-malignant diseases. Haploidentical HCT using post-transplant cyclophosphamide (PTCy) is a readily available option in the absence of an HLA- matched donor. We conducted a retrospective single-center study on the outcome of haploidentical HCT in children with non-malignant diseases. We gathered data from 44 patients underwent HCT in the period 2015 to 2020. The indications for HCT were bone marrow failure, primary immunodeficiency, metabolic disorders, and hemoglobinopathy. Median age at HCT was 4 years (range 0.7-20).The conditioning regimens were myeloablative (n=16), or reduced intensity (n=26). After a median follow-up of 20 months (range 4-71), 2-year overall survival was 89% and 2 year GvHD-free relapse-free survival (GRFS) was 66%. Incidence of primary graft failure was 13.6%. Cumulative incidence of grade II-IV acute and moderate/severe chronic GvHD were 20% and 6.4%, respectively. Younger age at HCT (p

Background The ongoing spread coronavirus disease worldwide has caused major disruptions and led to lockdowns. Everyday lifestyle changes and antenatal care inaccessibility during the coronavirus disease 2019 (COVID-19) pandemic have variable results that affect pregnancy outcomes. This study aimed to assess the alterations in stillbirth, neonatal-perinatal mortality, preterm birth, and birth weight during the COVID-19 national lockdown. Methods We used the data from the Jordan stillbirths and neonatal death surveillance system to compare pregnancy outcomes (gestational age, birth weight, small for gestational age, stillbirth, neonatal death, and perinatal death) between two studied periods (11 months before the pandemic (May 2019 to March 2020) vs. 9 months during the pandemic (April 2020 to March 1st 2020). Separate multinomial logistic and binary logistic regression models were used to compare the studied outcomes between the two studied periods after adjusting for the effects of mother’s age, income, education, occupation, nationality, health sector, and multiplicity. Results There were 31106 registered babies during the study period; among them, 15311 (49.2%) and 15795 (50.8%) births occurred before and during the COVID-19 lockdown, respectively. We found no significant differences in preterm birth and stillbirth rates, neonatal mortality, or perinatal mortality before and during the COVID-19 lockdown. Our findings report a significantly lower incidence of extreme low birth weight (ELBW) infants (P value Conclusions During the COVID-19 lockdown period, the number of infants born with extreme low birth weight (ELBW) decreased significantly. More research is needed to determine the impact of cumulative socio-environmental and maternal behavioral changes that occurred during the pandemic on the factors that contribute to ELBW infants.

Chronic active antibody-mediated rejection (AMR) in renal transplantation is usually refractory to current conventional treatment with rituximab, plasmapheresis (PP), and intravenous immunoglobulins (IVIG). Splenic irradiation has been reported to be effective in the rescue of early severe acute AMR after kidney transplantation; however, its effect in chronic active AMR has not been reported to date. In order to reduce donor-specific antibody (DSA) and prevent the progression of chronic AMR, we used repetitive low-dose splenic irradiation, together with rituximab and PP/IVIG, in two living-related kidney transplant recipients with pathologically diagnosed chronic active AMR and the presence of long-term class II-de novo DSA. DSA monitoring and repeated renal biopsy revealed significantly reduced DSA levels as well as alleviated glomerulitis and peritubular capillaritis in both patients after treatment, and these therapies may have played a role in delaying the progression of chronic AMR. Although DSA levels in both patients eventually rebounded to some extent after treatment, serum creatinine increased slowly in one patient during the 16-month follow-up period and remained stable in the other during the 12-month follow-up period. Given the poor efficacy of conventional treatment at present, splenic irradiation may still be one of the treatment options for chronic active AMR.

Context Burkitt lymphoma is a highly aggressive and rare non-Hodgkin lymphoma (NHL). Treatment with multidrug non-cross-resistant pediatric-inspired chemotherapy protocols usually results in high cure rates with significant toxicity. Here, we report our experience with the CALGB 1002 protocol in the treatment of adults with Burkitt lymphoma. Objective Assess the outcome of the CALGB 1002 protocol in Burkitt lymphoma and associated toxicity. Design A retrospective study with a median follow-up of 36 months. Files and medical records of adult patients diagnosed with Burkitt lymphoma and treated with CALGB 1002 protocol in King Hussein Cancer Center were reviewed from 2008 to 2017. Patients 19 patients were included, 12 (63%) were males. The median age was 33 years (range: 19–65). 11 patients (58%) had advanced-stage disease, 14 (73.6%) had extra-nodal involvement. CNS involvement was found in 2 patients (10.5%), and bone marrow involvement was found in 2 patients (10.5%). Results A total of 106 cycles were given, and the median time between cycles was 23 days (range: 19–84 days). 16 patients (84%) achieved complete response. After a median follow-up of 36 months, 3-year event-free survival and overall survival were 78.95%. 2 patients (10.5%) died because of chemotherapy-related toxicity. 2 patients (10.5%) died because of progressive disease. For toxicity: grade III–IV neutropenia and thrombocytopenia were found in 59% of chemotherapy cycles. Febrile neutropenia occurred after 52.9%, despite filgrastim and antibiotic prophylaxis. Grade III–IV mucositis complicated 48.2% of cycles. Hepatotoxicity and nephrotoxicity were reported in 47.2% and 15.1% of cycles, respectively. When stratifying patients according to the age at diagnosis ( Conclusions Although CALGB 1002 protocol can be timely administered to most adult Burkitt lymphoma patients, it is associated with significant toxicity. A risk-adapted approach and consideration of other, less toxic chemotherapeutic regimens should be considered, especially in the older age group.

Purpose Type 2 diabetes mellitus (T2DM) is a considerable impact on physical health as well as on emotional and social wellbeing. This study aimed to investigate the quality of life and its associated factors among Palestinians with T2DM. Methods A cross-sectional study including 517 patients (68% female) was conducted in eleven primary health care clinics located in Ramallah and al-Bireh governorate of the West Bank. To assess socio-demographic data, risk factors and diabetes control, interviews, physical examinations, anthropometric measurements, and blood and urine tests were performed. The validated Arabic version of the Audit of Diabetes-Dependent Quality of Life (ADDQoL) questionnaire was carried out on all patients to measure Quality of Life (QoL). A multivariable regression analysis was performed. Results The average weighted impact (AWI) score was −3.38 (95% CI: −3.55 to −3.21, range: −9.00 to 0.12). This indicates that diabetes was perceived as having a considerable negative impact on the quality of life. The life domains ‘freedom to eat’, ‘physical activities’, and ‘work-life’ were the most negatively impacted. Males and individuals living with diabetes for a prolonged time were associated with a more significant negative impact on quality of life. Conclusion The study showed that diabetes generally had a negative impact on QoL and identified the demand for diabetes management programs tailored to patient needs and different patient groups, as well as health policies that put patients in the center of diabetes care.

Simple Summary Leukemia, the most common form of childhood cancer, accounts for about 30 percent of all cancers that affect children and young adults. Although pain is a common and distressing symptom of childhood leukemia, evidence-based guidance regarding assessment and management is lacking. With 6 international multidisciplinary healthcare professionals, we aimed to review current evidence in literature, addressing diagnosis, assessment and pharmacological management of the most common leukemia-related pain syndromes in children, including cancer-related painful neuropathies and osteonecrosis. We also focus on the impact of pain on quality of life of childhood leukemia patients and the most common pain medications used in the pediatric population, with differences in their utilizations across countries. Abstract Pain is one of the most common symptoms in children suffering from leukemia, who are often misdiagnosed with other childhood painful diseases such as juvenile idiopathic arthritis. Corticosteroid-induced osteonecrosis (ON) and vincristine-induced peripheral neuropathy (VIPN) are the most common painful manifestations. Additionally, ongoing pain may continue to impact quality of life in survivorship. This narrative review focuses on the pathophysiological mechanisms of pain in childhood leukemia and current available indications for analgesic treatments. Pain management in children is often inadequate because of difficulties in pain assessment, different indications across countries, and the lack of specific pediatric trials. Analgesic drugs are often prescribed off-label to children by extrapolating information from adult guidelines, with possible increased risk of adverse events. Optimal pain management should involve a multidisciplinary team to ensure assessment and interventions tailored to the individual patient.

Background Radiation therapy for head and neck cancer (HNC) associates with an increase in cerebrovascular events. Amygdalar metabolic activity (AmygA), a measure of stress-associated neurobiological activity, associates with cardiovascular events in patients without cancer. In this study, we tested whether AmygA was associated with cerebrovascular events among patients treated with radiation therapy. Methods The associations between AmygA (at cancer staging) and subsequent cerebrovascular events as well as inflammatory biomarkers and arterial inflammation, were tested among consecutive patients with HNC treated with radiation therapy who underwent 18F-FDG-PET/CT. Results Among 240 patients (59±13 years; 30% female, 48% had stage 4 disease), there were 26 events over a median follow-up period of 3 years (IQR: 1.7–5.1). AmygA at cancer staging was associated with subsequent cerebrovascular events, an effect that remained significant after adjustment for age, sex, and cerebrovascular risk factors (adjusted hazard ratio 1.47, 95% CI 1.04–2.09, P=0.031). The association persisted when the analysis was restricted to patients with no prior history of CV disease and even among those with lower predicted CV risk (P Conclusions Amygdalar activity, a quantifiable biomarker of stress-associated brain activity, associated with subsequent cerebrovascular events among patients with cancer treated with radiation therapy. Funding Acknowledgement Type of funding source: None

BackgroundNeoadjuvant chemotherapy and short-course radiotherapy followed by resection has been gaining recognition in the treatment of rectal cancer. Avelumab is a fully human immunoglobulin that binds Programmed Death-Ligand 1 (PD-L1) and prevents the suppression of the cytotoxic T cell immune response. This phase II trial evaluates the safety and pathologic response rate of short-course radiation followed by 6 cycles of mFOLFOX6 with avelumab in patients with locally advanced rectal cancer (LARC).MethodsThis study is prospective single-arm, multicenter phase II trial adopting Simon’s two-stage. Short-course radiation is given over 5 fractions to a total dose of 25 Gy. mFOLFOX6 plus avelumab (10 mg/kg) are given every 2 weeks for 6 cycles. Total mesorectal excision is performed 3–4 weeks after the last cycle of avelumab. Follow up after surgery is done every 3 months to a total of 36 months. Adverse event data collection is recorded at every visit.Results13 out of 44 patients with LARC were enrolled in the first stage of the study (30% from total sample size). All patients met the inclusion criteria and received the full short-course radiation course followed by 6 cycles of mFOLFOX6 plus avelumab. 12 out of the 13 patients completed TME while one patient had progression of disease and was dropped out of the study. The sample consisted of 9 (69%) males and 4 (31%) females with median age of 62 (33–73) years. The first interim analysis revealed that 3 (25%) patients achieved pathologic complete response (pCR) (tumor regression grade, TRG 0) out of 12. While 3 (25%) patients had near pCR with TRG 1. In total, 6 out of 12 patients (50%) had a major pathologic response. All patients were found to be MMR proficient. The protocol regimen was well tolerated with no serious adverse events of grade 4 reported.ConclusionIn patients with LARC, neoadjuvant radiation followed by mFOLFOX6 with avelumab is safe with a promising pathologic response rate.Trial Registration Number and Date of RegistrationClinicalTrials.gov NCT03503630, April 20, 2018.https://clinicaltrials.gov/ct2/show/NCT03503630?term=NCT03503630&draw=2&rank=1.

PURPOSE The purpose of this study is to determine if there is a relationship between radiological parameters measured using a plain X-ray and DXA scan score, and whether a plain X-ray can be used as surrogate imaging modality when DXA scan is not readily available. METHODS We included all patients who had both a DXA scan and a pelvis X-ray done from 1 January 2013 to 31 December 2017. Bone mineral density had been measured by DXA scanning of the femoral neck and the spine. Osteoporosis was defined by T-score of any site less than -2.5. Cortical thickness indices on the AP radiograph were calculated. RESULTS Sixty patients were involved in the study and were divided into two groups. Group A had 22 patients who had a T-Score on their DXA Scans ≤-2.5 SD at the femur neck or the spine with median ± SD (-2.5 ± 0.8, -2.8 ± 1.0), respectively. Group B had 38 patients who had a T-score on their DXA Scans of >-2.5 at the femur neck and the spine with median ± SD (-1.2 ± 0.9, -1.3 ± 1.0), respectively, which was significantly higher than the T-score of osteoporotic (group A) patients (P = .000) at both sites of measurement. The cortical thickness index (CTI) was significantly higher (P = .027) in group B mean ± SD (0.56 ± 0.07), compared with (0.51 ± 0.08) that in group A. CONCLUSION DXA imaging remains the gold standard for diagnosing osteoporosis and we advocate the use of CTI to detect the patients who need DXA screening in places where this modality is not readily available.

Temporary mechanical circulatory support device (tMCS) failure could qualify patients with advanced heart failure to receive a long-term solution. We report on a patient who presented with cardiorespiratory arrest that required a tMCS and developed acute type A aortic dissection. Data Sources: our case adds further evidence regarding the support of a patient with a second (or more) incidence of tMCS. This patient subsequently underwent left ventricular assist device insertion and type A aortic dissection repair, as a combined procedure, with a satisfactory outcome.

The role of oral bacteremia and periodontal inflammation driving atherosclerosis is still under investigation. This review article highlights the role of periodontal inflammation and oral microorganisms in the development and progression of atherosclerosis and cardiovascular diseases. Association between periodontal and cardiovascular diseases has been well characterized, but causal correlation is yet to be established. For instance, untreated gingivitis can progress to periodontitis. Periodontal disease has been associated with several systemic diseases one of which is atherosclerosis. One possible association that was documented in literature is that poor oral hygiene leads to bacteremia, which in turn can cause bacterial growth over atherosclerotic coronary artery plaques and possibly worsen coronary artery disease. It is crucial that clinicians understand the association between periodontal and cardiovascular disease. A comprehensive treatment for periodontitis and re-establishment of a healthy periodontium can help in reduction of overall inflammation in the body. This may play an important role in prevention of cardiovascular disease, though future research is needed to establish this.

Background and Aims Autophagy is a catabolic mechanism that involves lysosomal-dependent degradation of unnecessary or dysfunctional intracellular components. Autophagy plays role in many biological processes, including diabetic nephropathy (DN) and diabetic retinopathy (DR). Autophagy-related gene 5 (ATG5) is one of the most important participants in the autophagy mechanism. Deficiencies in ATG5 protein levels are associated with several diseases by influencing the level of autophagy pathway. Our study's aim was to investigate if aberrant expression of ATG5 protein or Atg5 gene is associated with DN or DR. Method The study included 120 human participants in 4 groups – Healthy, diabetic (DM), DN and DR; and 10 mice in 2 groups – healthy and DN. Western blot analyses of ATG5 and its downstream collaborator LC3B were performed on human white blood cell (WBC) lysates and murine renal lysates. Immunohistochemical analysis was performed on mice renal tissues. Quantitative real-time PCR analysis of ATG5 was performed on total mRNA isolated from human WBC. Results Conclusion

Metronomic chemotherapy (M-CT) is defined as dose dense administration of chemotherapy at lower doses than maximum tolerated dose but at shorter free intervals, to obtain a near continuous exposure of cancer cells to those potentially effective drugs. M-CT is a useful strategy to obtain response, overcome resistance and reduce side effects, with low costs. This review will focus on the use of M-CT in advanced breast cancer (ABC). Cytostatic and cytotoxic effect on cancer cells, the anti-angiogenic and the immunomodulatory effects are its main mechanisms of actions. Many clinical trials proved the efficacy and tolerability of different monotherapies and combinations of chemotherapeutic agents administered in metronomic doses and frequencies in ABC. M-CT is a reasonable option for second and later lines of chemotherapy in metastatic breast cancer including those with prior anthracycline or taxane exposure, older patients and patients with comorbidities, and even as first-line in certain groups of patients. The acceptable efficacy and low toxicity of oral metronomic chemotherapy makes it a reasonable option during COVID-19 pandemic as well as in the post-COVID era which is projected to last for some time.

Dual-task paradigms have been increasingly used to assess the interaction between cognitive demands and the control of balance and gait. The interaction between functional and cognitive demands can alter movement patterns and increase knee instability in individuals with knee conditions, such as knee anterior cruciate ligament (ACL) injury or osteoarthritis (OA). However, there is no consensus on the effects of dual-task on gait mechanics and balance in those individuals. This systematic scoping review aims to examine the impact of dual-task gait and standing balance on motor and cognitive performance in individuals with knee OA or ACL injury. A comprehensive search of MEDLINE, PubMed, Web of Science, and EMBASE electronic databases up until December 2019 was carried out. Inclusion criteria was limited to include dual-task studies that combined cognitive tasks performed simultaneously with gait or standing balance in individuals with knee OA or ACL injuries. In total, fifteen studies met the inclusion criteria, nine articles examined dual-task effects on balance, and six articles reported the effects of dual-task on gait. The total number of individuals included was 230 individuals with ACL injuries, and 168 individuals with knee OA. A decline in gait and balance performance during dual-task testing is present among individuals with ACL injury and/or ACL reconstruction and knee OA. Further research is required, but dual taking assessment could potentially be used to identify individuals at risk of falling or further injury and could be used to develop targeted rehabilitation protocols. A variety of outcome measures have been used across the studies included, making comparisons difficult. The authors, therefore, recommend developing a standardized set of biomechanical balance variables.

The purpose of this study was to examine pathways through which childhood abuse increases the risk of cervical cancer, including smoking, stress, risky sexual behavior, and not having a Papanicolaou (Pap) test.This is a descriptive, correlational study. The sample included 410 women, recruited from a large, multisite women's health center that serves low-income communities in New Jersey. Data were analyzed using path models and conditional regression analysis.Overall, 15% and 12% of the women in the study reported history of physical and sexual childhood abuse, respectively. There was a significant association between child abuse history and failure to receive a Pap test (χChildhood abuse increases the risk of cervical cancer in adulthood, through failure to receive a Pap test and higher levels of smoking, perceived stress, and most importantly, risky sexual behavior. More importantly, the combination of childhood abuse and risky sexual behavior plays a greater role in increasing cervical cancer risk.

The aim of this review is to provide the information necessary for recognizing scleritis in rheumatology patients, recognize associated systemic diseases in scleritis patients referred to rheumatology, and choose the best conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologic therapy, based on the most recent data. Scleritis is most often associated with systemic conditions, particularly autoimmune conditions. Rheumatologists should be most vigilant about rheumatoid arthritis and ANCA-associated vasculitis. A recent systemic association has been found with IgG4-related disease as well. Most of the therapeutic decisions are based on observational data. Most recently, there is increasing evidence of the role of rituximab for refractory disease. Scleritis is a severe inflammatory ocular condition that leads to complications including vision loss. It can precede a systemic autoimmune disease diagnosis, especially in the case of vasculitis. Prompt recognition and adequate therapy are needed in order to avoid serious ocular complications. There is an unmet need for (1) head-to-heat trials on csDMARDs and biologic drugs for the treatment of idiopathic scleritis and (2) randomized controlled trials on the treatment of refractory cases.

Type 2 diabetes mellitus (T2DM) is a growing pandemic that will lead, if not managed and controlled, to frequent complications, poor quality of life, and high rates of disability and death. Little is known about T2DM complications in Palestine. The aim of this study is to estimate the prevalence of T2DM complications in Ramallah and al-Bireh governorate of Palestine.The study was conducted in eleven primary healthcare clinics offering services for persons with T2DM. Macrovascular complications were assessed using the Diabetes complication index. Microvascular complications were measured by physical examinations and laboratory tests. Questionnaires, laboratory tests, and physical examinations were used to assess socio-demographic characteristics, co-morbidities and other risk factors.517 adult men and nonpregnant women participated in the study (166 men, 351 women). The response rate was 84%. Mean age and mean duration of diabetes were 58.1 and 9.4 years respectively. Prevalence of diagnosed microvascular and macrovascular complications was 67.2% and 28.6% respectively. 78.2% of the participants had poor glycemic control (HbA1c≥7.0%).Significant proportions of persons with T2DM had macro- and microvascular complications and poor metabolic control. These findings are important for policy development and the planning of health services.

BACKGROUND Mutations in the three-prime repair exonuclease 1 (TREX1) gene have been associated with neurological diseases, including Retinal Vasculopathy with Cerebral Leukoencephalopathy (RVCL). However, the endogenous expression of TREX1 in human brain has not been studied. METHODS We produced a rabbit polyclonal antibody (pAb) to TREX1 to characterize TREX1 by Western blotting (WB) of cell lysates from normal controls and subjects carrying an RVCL frame-shift mutation. Dual staining was performed to determine cell types expressing TREX1 in human brain tissue. TREX1 distribution in human brain was further evaluated by immunohistochemical analyses of formalin-fixed, paraffin-embedded samples from normal controls and patients with RVCL and ischemic stroke. RESULTS After validating the specificity of our anti-TREX1 rabbit pAb, WB analysis was utilized to detect the endogenous wild-type and frame-shift mutant of TREX1 in cell lysates. Dual staining in human brain tissues from patients with RVCL and normal controls localized TREX1 to a subset of microglia and macrophages. Quantification of immunohistochemical staining of the cerebral cortex revealed that TREX1+ microglia were primarily in the gray matter of normal controls (22.7 ± 5.1% and 5.5 ± 1.9% of Iba1+ microglia in gray and white matter, respectively) and commonly in association with the microvasculature. In contrast, in subjects with RVCL, the TREX1+ microglia were predominantly located in the white matter of normal appearing cerebral cortex (11.8 ± 3.1% and 38.9 ± 5.8% of Iba1+ microglia in gray and white matter, respectively). The number of TREX1+ microglia was increased in ischemic brain lesions in central nervous system of RVCL and stroke patients. CONCLUSIONS TREX1 is expressed by a subset of microglia in normal human brain, often in close proximity to the microvasculature, and increases in the setting of ischemic lesions. These findings suggest a role for TREX1+ microglia in vessel homeostasis and response to ischemic injury.

Objective Hidradenitis suppurativa (HS) is an inflammatory skin condition that can cause profound morbidity. Patients can present with recurrent nodules, sinus tract formation, abscesses, and/or scarring, mainly affecting the intertriginous areas. Case reports have documented the coexistence of HS and inflammatory eye disease (IED). Herein, we aimed to assess the types of IED associated with HS and the outcomes of IED treatment in patients with HS. Methods All the cases with a diagnosis of HS and any IED were identified. Patients with episcleritis and sicca were excluded, and only those with chronic IED were included. An independent ophthalmologist reviewed notes to ensure accuracy of IED diagnosis. Demographics, IED patterns, comorbidities, treatments, and outcomes were retrieved from patient charts. Results Twenty patients [16 females (80%); 12 African Americans (60%)] were included in this study after the exclusion of 436 cases due to lack of data. The mean age at the diagnosis of HS and IED was 42.1 and 43.6 years, respectively. Thirteen patients had uveitis (65%), six had scleritis (30%), and one had peripheral ulcerative keratitis. Thirteen out of 20 patients (65%) had multiple autoimmune and/or inflammatory comorbidities, including inflammatory bowel disease, rheumatoid arthritis, ankylosing spondylitis, multiple sclerosis, and lupus. Seven patients (35%) did not have any comorbid inflammatory/autoimmune conditions. Conclusion One-third of the patients with HS and IED did not have any autoimmune or inflammatory comorbidity that could explain the eye involvement. The potential association between HS and IED might be a manifestation of a common immune dysregulation phenomenon. Furthermore, the management of IED required an escalation of therapy to systemic immunosuppressive agents in 70% of patients with HS.

Introduction Patients with Fanconi anemia have an increased susceptibility to malignancies associated with human papillomavirus, and thus prevention and early management of human papillomavirus infections in this patient population are crucial. Case report A nine-year-old girl with Fanconi anemia developed genital warts about three years after undergoing haplo-identical stem cell transplant. The transplant was complicated by chronic graft-versus-host disease, and the patient had therefore received multiple immunosuppressants. The genital warts were treated with several creams, but minimal improvement was reported. Management and outcome Cidofovir was extemporaneously compounded into an unscented 1% moisturizing cream and applied daily at bedtime to the genital warts. By the end of treatment, the warts had been successfully treated, and no adverse events were reported. The patient is still free of any lesions at six months after completing treatment. Discussion Although reports have been published on the use of cidofovir cream, most were in adults with non-genital warts. Cidofovir cream may be considered as a treatment option for refractory genital warts in pediatric patients. However, further studies are needed to better define the optimal preparation and dosing for such patient population.

COVID-19 is a newly diagnosed entity that has been identified for about 6 months. With the US now being the prevalent nation affected, we aimed to identify factors that were relevant to survival and hematological events in COVID patients. Our group had primarily been assessing COVID-19 confirmed patients as per PCR at Ochsner Medical Center in Louisiana; we primarily studied patients who were admitted between January 2020 to May 2020. Our main events that are currently being studied include factors such as mortality, length of stay, and bleeding or thrombotic events. Secondary endpoints included factors such as influence on blood type and also amount of transfusions required by these patients. Our overall analysis of 1773 patients yielded a number of 60 patients who were able to identify as having an active cancer diagnosis. This disproportionate number of patients may be related to factors such as reluctance to visit the hospital among cancer patients, a phenomenon noted similarly in Cardiology where the number of admissions for cardiac causes had declined suddenly during this pandemic timeline. Our half of our population was African American and included an even proportion of males and females. The age range of patients was between 35-93 years old. The most common malignancies that were noted to co-occur with COVID-19 in our population seemed to be lung, prostate, and hematological malignancies. Although final analyses regarding mortality are to be completed, the proportion of patients who had died with a diagnosis of cancer was around 50% per collection of our current data. Twenty three out of 60 (38%) patients required blood transfusions. In comparison to other reports which had reported bleeding events and thrombotic events, our report had revealed a much less rate of bleeding events (5/60) and thrombotic events (5/60). We plan to repeat our analysis to assess for any confounders in identifying these events, as noted, since some earlier literature had reported between ¼ to ⅔ of patients having a thrombotic event. Our analysis also looks at other descriptive variables such as use of anticoagulant and antiplatelet agents, absolute counts of neutrophils and lymphocytes, platelets, and coagulation markers. Also, our assessment includes a study in assessment of any delays noted in chemotherapy dates for these patients. Analysis of assessment of bleeding, thrombosis, and mortality for the entire patient group is currently in process. Disclosures No relevant conflicts of interest to declare.