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Background Celiac disease is an autoimmune disorder that causes an intolerance to gluten. Owing to hidden sources, lack of clear labeling, and cross-contamination, it is not uncommon for individuals with celiac disease to inadvertently ingest gluten. A strict gluten-free diet is the only treatment. Objectives The purpose of this study was to identify the frequency of activated charcoal use in celiac disease as a purported remedy despite the lack of literature on the safety and efficacy of the practice and to elucidate the manner in which using activated charcoal as a treatment for acute gluten ingestion is being communicated. Methods Using a descriptive study design, a Web-based survey was sent to members of the celiac disease community via social media pages for voluntary participants 18 years and older diagnosed with celiac disease. Participants were stratified into 3 major groups: (1) those who had heard of using activated charcoal as a remedy to counteract gluten ingestion and used it, (2) those who had heard of using activated charcoal but had not used it, and (3) those who had not heard of using activated charcoal. Results In subjects with celiac disease, 424 of 1613 respondents (26%) had heard of using activated charcoal as a potential remedy for gluten ingestion, and 12% had used it. The top source of information regarding any general information including remedies for maladies related to celiac disease was social media networks 72.3% (879/1613). Of those who had used activated charcoal, 122 participants (61.3%) reported subjectively feeling a reduced severity of symptoms. Conclusion Pharmacists should be aware of the off-label use of activated charcoal for accidental gluten ingestion in celiac disease. Pharmacists should educate patients with celiac disease that there is not sufficient evidence to support the use of activated charcoal.

To evaluate the noninferiority of intraocular pressure (IOP)-lowering latanoprost without benzalkonium chloride (BAK) versus latanoprost with BAK (for treatment of open-angle glaucoma or ocular hypertension).Overall, 578 patients were randomized 1:1 to latanoprost without BAK or latanoprost with BAK once daily in the affected eye(s) for 12 weeks. The primary efficacy endpoint was IOP, measured on days 0, 7, 28, 56, and 84 (8 am, 10 am, and 4 pm). Noninferiority was established if the following criteria were met: 95% confidence interval (CI) of the mean difference between treatments included 0 mm Hg for all time points (N1), 95% CI upper limit less than 1.5 mm Hg (N2), and less than 1 mm Hg for≥7 of 12 time points (N3). Primary efficacy analysis was performed on the intent-to-treat population. Safety measurements included ocular and systemic adverse event (AE).The 95% CI included 0 mm Hg for 7/12 time points (N1), 95% CI upper limit was less than 1.5 mm Hg for 12/12 time points (N2), and less than 1.0 mm Hg for 4/7 time points (N3). AEs were mild and similarly distributed between groups.Latanoprost without BAK did not meet two of three criteria for noninferiority and showed a similar safety profile relative to latanoprost with BAK.

Author(s): Barr-Walker, Jill; DePineres, Teresa; Ossom-Williamson, Peace; Mengesha, Biftu; Berglas, Nancy F | Abstract: Misinformation about abortion abounds in the United States. This may be due, in part, to laws in 22 states that require health care providers to present medically inaccurate or misleading information to people seeking abortion. Such information can negatively impact both providers and patients, particularly vulnerable populations who already face considerable challenges accessing abortion services. Health sciences librarians are a professional group whose core values prioritize access to evidence-based health information for all people, with the goal of facilitating informed health care decisions. This professional imperative suggests a role for librarians in the provision of evidence-based information around abortion. Drawing on our collective expertise in library science, medicine and public health, we propose that health sciences librarians build partnerships with public health departments and abortion providers to develop authoritative resources, advocate for change through legislative action, and raise public awareness about abortion misinformation.

This analysis considered the sonographic patterns of uterine myoma seen at the Central Hospital in Warri, Delta State, Nigeria. Ultrasonographic records of the uteri of 312 women seen from December 2017 to January 2021 were retrieved from the Central Hospital in Warri, Nigeria. Information on the leiomyoma size, weight, occurrence site, types and number of nodules were fetched from available ultrasonographic reports. Ethical approval was obtained from the Research/ Ethical Committee of Human Anatomy Department at the Delta State University, Abraka, and the Warri Central Hospital. Data was entered into Statistical Package for the Social Sciences (version 23). Results were presented in mean and simple percentage of occurrences of sampled parameters. The chi-square test was used to obtain association between categorical variables, while setting p-value < 0.05 as statistically significant. A total of 312 cases of women with leiomyoma were detailed. The 45-50 years age group had the highest frequency of 52 (16.7%). Regarding the location of the leiomyoma in the different parts of the uterus, the anterior corpus was the commonest site of occurrence of the leiyomyoma accounting for a frequency of 80 (25.6 %) while the fundus had the least frequency of 53 (17%). Based on volume and number of observed nodules, about 160 (51.3%) of assessed leiomyoma lesions were > 200cm3, whereas 152 (48.7%) were < 200cm3. Also, 1-5 nodules were observed in 117 cases, accounting for about 37.5% of the leiomyoma lesions. Conclusively, this study has shown that an insignificant association exists between patient age and the weight, size, type and number of nodules of leiyomyoma Keywords: Leiomyoma, uterine, myoma, ultrasonography.

This study has two aims: determine the prevalence of CIN3 + in patients with discordant cotesting, defined as negative cytology and positive human papillomavirus (HPV) testing, and identify factors (including HPV strain) associated with CIN3 + , defined as cervical intraepithelial neoplasia (CIN) 3 or cancer within this population. We conducted a retrospective chart review of women age 30–65 with intact cervices who had discordant cotesting results between January 1, 2013 and September 1, 2018, at an academic medical center. We used the t test for continuous variables and the Chi-square test for categorical variables to compare women with and without CIN3 + . To identify factors associated with CIN3 + , we performed univariate and multivariate logistic regression. The primary outcome was the prevalence of CIN3 + based on pathologic diagnosis following biopsy or excisional procedure. Among 375 patients with discordant co-testing, the mean age was 43.8 years, 58.4% were parous, and 84.8% were white. Overall, 43/375 (12.0%) had CIN3 + and 7/375 (1.9%) had AIS. On logistic regression, only parity ≥ 1 (p = 0.04, adjusted OR = 2.23, CI = 1.06–4.68) was significantly associated with CIN3 + . HPV-18 was less likely to be associated with CIN3 + (p = 0.02, adjusted OR 0.08, CI 0.01–0.65) but was present in 43% of AIS cases. HPV16 and other HR-HPV strains were highly associated with CIN3 + . Women with discordant cotesting are at significant risk for CIN3 + . We recommend that biopsy be performed at the time of indicated colposcopy for all patients with discordant cotesting to assess for high-grade dysplasia.

Background This is a case report of an asymptomatic SARS-CoV-2 infection associated with new-onset nephrotic syndrome in a pediatric patient. This is the third case of new-onset nephrotic syndrome in children associated with SARS-CoV-2 infection, but is the first case report describing a new-onset nephrotic syndrome presentation in a patient who had asymptomatic COVID-19 infection. Case presentation This is a case of a previously healthy 5 year old female who presented with new-onset nephrotic syndrome in the setting of an asymptomatic COVID-19 infection. She presented with progressive edema, and laboratory findings were significant for proteinuria and hypercholesterolemia. She was treated with albumin, diuretics, and corticosteroid therapy, and achieved clinical remission of her nephrotic syndrome within 3 weeks of treatment. Though she was at risk of hypercoagulability due to her COVID-19 infection and nephrotic syndrome, she was not treated with anticoagulation, and did not develop any thrombotic events. Conclusions Our case report indicates that SARS-CoV-2 infection could be a trigger for nephrotic syndrome, even in the absence of overt COVID-19 symptoms.

Background The majority of COVID-19 research has been devoted to characterizing the epidemiology and early clinical aspects of the virus. In Lagos, Nigeria, we looked at the temporal progression of COVID-19 patients. We included 1337 confirmed COVID-19 cases in our study from February 27th to March 27th 2020. Of the 1337 patients enrolled, the median age was 50 years old, and 800 (59.83%) were male while 537 (40.16%) were female. Method In symptomatic patients, the time from the beginning of signs to admission was 4 (2–7) days. Fever occurred in 217 (16.2%) while cough occurred in 211(15.78%) patients respectively. Patients were given 5–6 treatment, including nutrition support, supplementary oxygen, and antiviral medicines (e.g., Remdesivir, dexamethasone) in a limited percentage of cases. The assessed median period of infection in all patients was 10 days after the start of symptoms (95 confidential intervals [CIs]: 8–11 days). The duration of fever was slightly longer in patients admitted to intensive care units (ICU) than in those who were not (31 days versus 9 days, respectively, P Results On day 7 after the onset of symptoms, radiological deterioration of the original picture was found in 500 (37.39%) patients. On day 13, 154 of these patients (94.5%) showed signs of radiological improvement. The average time it took for upper respiratory tract samples to test negative for reverse transcriptase PCR was 10 days (90 percent confidence interval: 10–12 days). Virus clearance was more significant in ICU patients than in non-ICU patients (P Conclusions Community members should continue to adhere to the recommended methods of preventing the spread of COVID-19 infection and patients should seek care early to reduce the risk of mortality associated with the infection as rapidly as possible.

PURPOSE OF THE REVIEW: Biliary atresia (BA) is the leading cause of chronic liver disease and the most common indication for pediatric liver transplantation. The use of ultrasound (US) and related techniques continues to evolve help diagnose BA as well as potentially to help predict outcomes after treatment with the Kasai portoenterostomy (KP). RECENT FINDINGS: There are no US findings which are definitive for BA; however, signs which are consistent with BA include gallbladder abnormalities, the triangular cord sign, presence of hepatic subcapsular flow, and hilar lymphadenopathy. Elastography techniques to measure liver stiffness may also increase the diagnostic accuracy of detecting BA, particularly in older infants or without other ultrasound findings. In addition, both US and elastography are still being studied as potential methods to predict outcomes after KP such as development of portal hypertension and need of for liver transplant. SUMMARY: US findings in the diagnosis of BA are well-characterized. Future studies will help determine the utility of elastography in diagnosing BA, as well as both US and elastography in monitoring and predicting disease outcomes after KP.

Objective: To test an intervention to increase screening for hepatitis B (HBV) in at-risk immigrants in the primary care setting. Patients and Methods: From a Mayo Clinic primary care panel, we identified approximately 19,000 immigrant patients from 9 high-risk countries/ethnic groups with intermediate or high prevalences of chronic HBV. Eligible patients with no record of prior HBV testing scheduled for primary care visits within the study period spanning October 1, 2017, through October 31, 2018, were identified. During the intervention period, the primary health care professional was notified by email 1 week prior to each primary care visit and encouraged to discuss screening for HBV infection and order screening tests at the appointment. We assessed rates of HBV screening during control and intervention periods. Results: We identified 597 patients in the control period and 212 patients in the intervention period who had not been screened previously for HBV. During the intervention period, 31.4% (58) of the 185 eligible patients were screened for HBV vs 7.2% (43) of the 597 eligible patients in the control period. Thus, the intervention resulted in a 4.3-fold increase in screening (P

PURPOSE Burkitt lymphoma (BL) has unique biology and clinical course but lacks a standardized prognostic model. We developed and validated a novel prognostic index specific for BL to aid risk stratification, interpretation of clinical trials, and targeted development of novel treatment approaches. METHODS We derived the BL International Prognostic Index (BL-IPI) from a real-world data set of adult patients with BL treated with immunochemotherapy in the United States between 2009 and 2018, identifying candidate variables that showed the strongest prognostic association with progression-free survival (PFS). The index was validated in an external data set of patients treated in Europe, Canada, and Australia between 2004 and 2019. RESULTS In the derivation cohort of 633 patients with BL, age ≥ 40 years, performance status ≥ 2, serum lactate dehydrogenase > 3× upper limit of normal, and CNS involvement were selected as equally weighted factors with an independent prognostic value. The resulting BL-IPI identified groups with low (zero risk factors, 18% of patients), intermediate (one factor, 36% of patients), and high risk (≥ 2 factors, 46% of patients) with 3-year PFS estimates of 92%, 72%, and 53%, respectively, and 3-year overall survival estimates of 96%, 76%, and 59%, respectively. The index discriminated outcomes regardless of HIV status, stage, or first-line chemotherapy regimen. Patient characteristics, relative size of the BL-IPI groupings, and outcome discrimination were consistent in the validation cohort of 457 patients, with 3-year PFS estimates of 96%, 82%, and 63% for low-, intermediate-, and high-risk BL-IPI, respectively. CONCLUSION The BL-IPI provides robust discrimination of survival in adult BL, suitable for use as prognostication and stratification in trials. The high-risk group has suboptimal outcomes with standard therapy and should be considered for innovative treatment approaches.

Objective To explore the effect of metformin on therapeutic outcomes in cancer patients undergoing radiotherapy. Methods A literature search of the electronic databases was conducted to retrieve articles that investigated the effect of metformin on radiotherapy. Timeframe of electronic search ranged from the inception of each database to May 2020. These databases include PubMed, Embase and Scopus. Results From an initial search of 142 articles, and after the removal of duplicates as well as applying the inclusion and the exclusion criteria, 20 articles were finally included in this systematic review. Results from the reviewed clinical studies showed promising therapeutic effect of the combination of metformin with radiotherapy. Metformin has promising therapeutic effects as an adjuvant with radiotherapy. Conclusions The use of metformin as an adjuvant with radiotherapy should be treated with caution, as further studies investigating its optimal dose as well as molecular mechanisms are still needed.

Introduction: Health Care Workers are major influencers in vaccination, thus their acceptance or hesitancy to the covid-19 vaccine would either aid its acceptance among the populace. Materials and Methods: The study was a cross-sectional survey using a self-administered questionnaire from December 15, 2020 to January 10, 2021 among healthcare providers living in Nigeria. The questionnaire was made up of segments that include demographics information, knowledge of the COVID-19 vaccine, its acceptance or hesitancy. The questionnaire was fashioned using Likert scale multiple questions of three options: YES, NO, and I Don’t know (No opinion) and Aware, Somewhat aware, and Not aware. Data collected were entered into the spreadsheet using IBM SPSS version 22.0 statistical software and analyzed with descriptive statistics. The results were presented as percentages, frequency, tables, and figures. Results: A total of 1094 responses were retrieved. The majority are males (56.67%) with 36.93% of the respondents aged 30–39 years. PHC Worker forms 14.90% of the respondents and social media was the greatest source of information. A percentage of 45.74% have no confidence in the vaccine and 39.68% rejecting, the majority been males (47.38%). The reasons for hesitancy are concerns of effectiveness, side effects, fear of the unknown, and safety. The highest rejection was by Dental Technicians (53.03%) while the highest acceptance was Medical consultants (72.22%). Conclusion: The study shows that about 3 out of every 10 health workers showed COVID-19 vaccine hesitancy for various reasons. The study recommends effective education, training, and public enlightenment to change the narrative.

Background : World wide, numerous studies have shown a significant association between periodontitis and prematurity and/ or low birth weight particularly in developing countries. Periodontitis has been documented as public health concern but its association with preterm and /or low birth weight remains uncertain, thus the objective of this scoping review is to summarize the most recent published evidence related to the effect of periodontitis on preterm birth and low birth weight. Methods Hinari, PubMed, and Google Scholar were searched to acquire the published literature. The retrieved studies included cross-sectional, case control studies and randomized controlled trials with available full text published in English from 2008 to 2019. The key words used to identify relevant articles for review included the following: periodontitis, periodontal disease, pregnancy, preterm birth, and low birth weight. Results : 333 articles were identified initially after combining all the key words, with only 133 eligible articles published from 2008 to 2019. After review of the available 50 full text articles, duplicates were removed and 15 studies fully met the inclusion criteria. 13 articles supported the association between maternal periodontitis and preterm and/ or low birth weight while 2 found no evidence to support the association. Although we did not appraise methodological quality or risk of bias of the selected studies, as per the guidelines for scoping reviews, good quality and up to date studies were selected. However, there were some inconsistencies in the findings due to differed case definitions, study settings and sample. Conclusion : The results of this scoping review are consistent with a previous review of case-control studies only, thereby contributing to an increasing body of evidence to support the hypothesis that periodontal disease may be a risk factor for preterm delivery and low birth weight. More rigorous studies with larger prospective cohorts are needed to provide more conclusive frameworks for testing the suspected clinical association between maternal periodontitis and perinatal outcomes.

Food Safety is of growing concern globally, and more so considering the relatively high proportion of soft drinks in the beverage market worldwide, and its rate of consumption especially amongst the youths. It is essential to evaluate the levels of toxic metals and Polycyclic Aromatic Hydrocarbons (PAHs) residues of which when present in soft drinks above the permissible limits could pose serious public health risk. The aim of this present study was to assess the levels of heavy metals (Pb, Hg, Cd ,As) and Polycyclic aromatic Hydrocarbons(PAHs) in 16 commercial soft drinks marketed in Awka, using Atomic Absorption Spectroscopy(AAS) and Flame Ionization detector (GC-FID), respectively. The carcinogenic and non-carcinogenic risk assessment were performed using the method established by United State Environmental Protection agency(USEPA).The data obtained were compared with the permissible limit set for drinking water by United State Environmental Protection Agency(USEPA),World Health Organization (WHO),Standard Organization of Nigeria(SON) and Federal Environmental Protection Agency(FEPA). The highest mean level of 0.6116 mg/l is related to Pb and the lowest of 0.0028mg/l related to Hg. The mean levels of the metals increased in this order: Hg1, and thus, pose a health risk. The hazard index, calculated as the combined risk of heavy metal toxicity is greater than unity (HI>1).The incremental lifetime cancer risk (ILCR) values estimated for Pb, As and Cd in the sample were 6.25%,31.25% and 25% ,respectively, representing higher than acceptable risk value of (10-6 -10-4) . The results raise a concern for the public exposed with respect to As and Cd carcinogenic risk values. Â

Cancer data from population-based cancer registries under-report cancer cases, especially for cancers primarily diagnosed and treated in outpatient clinical settings, away from hospital-based cancer registrars. Previously, we developed alternative methods of cancer case capture including a claims-based method, which identified a large proportion of cancer cases missed by traditional population-based cancer registries. In this study, we adapted a claims-based method for statewide implementation of cancer surveillance in Florida. Between 2010 and 2017 the claims-based method identified 143,083 cancer abstracts, of which 42% were new and 58% were previously registered. The claims-based method led to the creation of 53,419 new cancer cases in the state cancer registry, which made up 9.3% of all cancer cases registered between 2010 and 2017. The types of cancers identified by the claims-based method were typical of the kinds primarily diagnosed and treated in outpatient oncology clinic settings, such as hematological malignancies, prostate cancer, melanoma, breast cancer, and bladder cancer. These cases were added to the Florida cancer registry and may produce an artefactual increase in cancer incidence, which is believed to be closer to the actual burden of cancer in the state.

Background. BL is a rare, high-grade B-cell lymphoma that is often studied in trials with small sample sizes. Historical definitions of "low-risk BL" vary between studies, use arbitrary cutoffs for lactate dehydrogenase (LDH), and identify a small favorable group, leaving >80-90% of patients (pts) in an undifferentiated "high-risk" category. A validated prognostic index will help compare study cohorts and better define good-prognosis pts for whom reduced treatment would be appropriate vs a poor-prognosis group in need of new approaches. Herein, we constructed and validated a simplified prognostic model for BL applicable to diverse clinical settings across the world. Methods. We derived the BL-IPI from a large real-world evidence cohort of US adults treated for BL in 2009-2018 (Evens A, Blood 2020). Progression-free survival (PFS) from diagnosis until BL recurrence, progression, death, or censoring was the primary outcome. We first determined the best prognostic cutoffs for age, LDH (normalized to local upper limit normal, ULN), hemoglobin (Hgb), and albumin. Independent risk factors were ascertained by forward stepwise selection into Cox regression from candidate variables: age, sex, HIV+ status, ECOG performance status (PS) ≥2, advanced stage (3/4), involvement of >1 extranodal site, bone marrow, central nervous system (CNS), values of LDH, Hgb, and albumin. Derivation models used multiple imputation to mitigate bias from missing data and reported hazard ratios (HR) with 95% confidence interval (CI). BL-IPI groups, defined by inspection of survival curves, were compared using log-rank test for trend. We validated performance of the BL-IPI in an external retrospective dataset of BL pts treated contemporaneously in centers from the United Kingdom, Scandinavia, Canada, and Australia. Results. Characteristics of pts in the derivation (N= 633) and validation (N=457) cohorts are shown in the Table. Age ≥40 years (yr), LDH >3xULN, Hgb 3xULN, low Hgb, and low albumin were associated with inferior PFS in univariate tests. In the multivariable model age ≥40 yr, LDH >3xULN, PS ≥2, and CNS involvement were selected as 4 independent prognostic factors; adding stage did not enhance the model. The model was simplified to 3 groups with 0 (low risk; 18% of pts), 1 (intermediate risk; 36% of pts; HR=3.14; 95%CI, 1.61-6.14), or 2-4 factors (high risk; 46% of pts; HR=6.52; 95%CI, 3.48-12.20; Fig A) with 3 yr PFS of 92%, 72%, and 53%, respectively (P Among pts with stage III/IV (historically classified as "high-risk" and constituting 78% of all pts in the cohort), the BL-IPI further discriminated subgroups with 3 yr PFS of 87%, 71%, and 52%, respectively (P In the international validation cohort, fewer pts had CNS involvement; most received CODOX-M/IVAC+R; and PFS/OS estimates at 3 yr were higher. BL-IPI categories were of similar size (low-risk 15%, intermediate-risk 35%, high-risk 50%), and provided similar risk discrimination (Harrell's C=.65 in both datasets). PFS at 3 yr was 96%, 82%, and 63%, respectively (P Conclusions. BL-IPI is a novel prognostic index specific to BL, which was validated to allow for simplified stratification and comparison of risk distribution in geographically diverse cohorts. The index identified a low-risk group with PFS >90-95%, which could be targeted with future strategies for treatment de-escalation. Conversely, only about 55-60% of pts in the high-risk group achieved cure with currently available immunochemotherapy. Disclosures Olszewski: Spectrum Pharmaceuticals: Research Funding; Genentech, Inc.: Research Funding; TG Therapeutics: Research Funding; Adaptive Biotechnologies: Research Funding. Jakobsen:Takeda: Honoraria. Collins:ADC Therapeutics: Consultancy, Honoraria; Celleron: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Speakers Bureau; Amgen: Research Funding; BeiGene: Consultancy; BMS: Consultancy, Honoraria, Research Funding, Speakers Bureau; Gilead: Consultancy, Honoraria, Speakers Bureau; MSD: Consultancy, Honoraria, Research Funding; Taekda: Consultancy, Honoraria, Other: travel, accommodations, expenses, Speakers Bureau; Roche: Consultancy, Honoraria, Other: travel, accommodations, expenses , Speakers Bureau; Pfizer: Honoraria; Celgene: Research Funding. Cwynarski:Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel Support; Atara: Consultancy, Membership on an entity's Board of Directors or advisory committees; Gilead: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; KITE: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel Support, Speakers Bureau; Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel Support, Speakers Bureau; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees; Roche: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel Support, Speakers Bureau. Bachanova:Incyte: Research Funding; Karyopharma: Membership on an entity's Board of Directors or advisory committees; BMS: Research Funding; FATE: Research Funding; Kite: Membership on an entity's Board of Directors or advisory committees; Gamida Cell: Membership on an entity's Board of Directors or advisory committees, Research Funding. Danilov:Abbvie: Consultancy; BeiGene: Consultancy; Nurix: Consultancy; Celgene: Consultancy; Gilead Sciences: Research Funding; Takeda Oncology: Research Funding; Pharmacyclics: Consultancy; Bayer Oncology: Consultancy, Research Funding; Genentech: Consultancy, Research Funding; TG Therapeutics: Consultancy; Astra Zeneca: Consultancy, Research Funding; Verastem Oncology: Consultancy, Research Funding; Karyopharm: Consultancy; Aptose Biosciences: Research Funding; Bristol-Myers Squibb: Research Funding; Rigel Pharmaceuticals: Consultancy. Diefenbach:Trillium: Research Funding; Millenium/Takeda: Research Funding; MEI: Research Funding; Merck: Consultancy, Research Funding; Seattle Genetics: Consultancy, Research Funding; Bristol-Myers Squibb: Consultancy, Research Funding; Genentech, Inc.: Consultancy, Research Funding; Incyte: Research Funding; LAM Therapeutics: Research Funding; Denovo: Research Funding. Epperla:Pharmacyclics: Honoraria; Verastem Oncology: Speakers Bureau. Farooq:Kite, a Gilead Company: Honoraria. Feldman:Pfizer: Research Funding; Portola: Research Funding; Janssen: Speakers Bureau; AstraZeneca: Consultancy; Cell Medica: Research Funding; Seattle Genetics, Inc.: Consultancy, Honoraria, Other: Travel expenses, Research Funding, Speakers Bureau; Viracta: Research Funding; Trillium: Research Funding; Rhizen: Research Funding; Corvus: Research Funding; BMS: Consultancy, Honoraria, Research Funding; Kite: Honoraria, Other: Travel expenses, Speakers Bureau; Celgene: Honoraria, Research Funding; Takeda: Honoraria, Other: Travel expenses; Amgen: Research Funding; Pharmacyclics: Honoraria, Other, Speakers Bureau; Abbvie: Honoraria; Bayer: Consultancy, Honoraria; Eisai: Research Funding; Kyowa Kirin: Consultancy, Research Funding. Gerrie:AbbVie: Consultancy, Honoraria, Research Funding; Astrazeneca: Consultancy, Research Funding; Janssen: Consultancy, Honoraria, Research Funding; Roche: Research Funding; Sandoz: Consultancy. Jagadeesh:Regeneron: Research Funding; Seattle Genetics: Membership on an entity's Board of Directors or advisory committees, Research Funding; Debiopharm Group: Research Funding; MEI Pharma: Research Funding; Verastem: Membership on an entity's Board of Directors or advisory committees. Kamdar:BMS: Consultancy; Abbvie: Consultancy; Karyopharm: Consultancy; Celgene: Consultancy; AstraZeneca: Consultancy; Pharmacyclics: Consultancy; Seattle Genetics: Speakers Bureau. Karmali:Takeda: Research Funding; AstraZeneca: Speakers Bureau; BeiGene: Speakers Bureau; Karyopharm: Honoraria; BMS/Celgene/Juno: Honoraria, Other, Research Funding, Speakers Bureau; Gilead/Kite: Honoraria, Other, Research Funding, Speakers Bureau. Khan:Seattle Genetics: Research Funding; Janssen: Honoraria; Pharmacyclics: Honoraria; Bristol Myers Squibb: Research Funding; Celgene: Research Funding. Klein:Takeda: Membership on an entity's Board of Directors or advisory committees. Lossos:Verastem: Consultancy, Honoraria; Stanford University: Patents & Royalties; Seattle Genetics: Consultancy, Other; Janssen Biotech: Honoraria; NCI: Research Funding; Janssen Scientific: Consultancy, Other. Lunning:ADC Therapeutics: Consultancy; Legend: Consultancy; Acrotech: Consultancy; AstraZeneca: Consultancy, Honoraria; Aeratech: Consultancy, Honoraria; Beigene: Consultancy, Honoraria; Verastem: Consultancy, Honoraria; TG Therapeutics: Research Funding; Novartis: Consultancy, Honoraria; Kite: Consultancy, Honoraria; Karyopharm: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; Gilead: Consultancy, Honoraria; Curis: Research Funding; Bristol Meyers Squibb: Consultancy, Honoraria, Research Funding. Martin:I-MAB: Consultancy; Celgene: Consultancy; Teneobio: Consultancy; Karyopharm: Consultancy, Research Funding; Janssen: Consultancy; Sandoz: Consultancy; Bayer: Consultancy; Beigene: Consultancy; Cellectar: Consultancy; Incyte: Consultancy; Kite: Consultancy; Morphosys: Consultancy; Regeneron: Consultancy. Martinex-Calle:Abbvie: Other: Travel grant. Naik:Celgene: Other: advisory board; Sanofi: Other: advisory board. Palmisiano:Genentech: Research Funding; AbbVie: Research Funding. Phillips:Beigene: Honoraria; Roche: Research Funding. Phillips:Seattle Genetics: Consultancy; Incyte: Consultancy, Other: travel expenses; AstraZeneca: Consultancy; Karyopharm: Consultancy; Beigene: Consultancy; Bayer: Consultancy, Research Funding; BMS: Consultancy; Pharmacyclics: Consultancy; Abbvie: Consultancy, Research Funding; Cardinal Health: Consultancy. Portell:Roche/Genentech: Consultancy, Research Funding; Infinity: Research Funding; Bayer: Consultancy; Amgen: Consultancy; TG Therapeutics: Research Funding; AbbVie: Research Funding; Pharmacyclics: Consultancy; Janssen: Consultancy; Kite: Consultancy, Research Funding; Acerta/AstraZeneca: Research Funding; Xencor: Research Funding; BeiGene: Consultancy, Research Funding. Reddy:Celgene: Consultancy; BMS: Consultancy, Research Funding; Genentech: Research Funding; Abbvie: Consultancy; KITE Pharma: Consultancy. Yazdy:Abbvie: Consultancy; Genentech: Research Funding; Octapharma: Consultancy; Bayer: Honoraria. Smith:Bristol Meyers Squibb: Research Funding; Ayala: Research Funding; Seattle Genetics: Research Funding; Portola: Research Funding; Pharmacyclics: Research Funding; Merck: Research Funding; Incyte: Research Funding; Ignyta: Research Funding; Genentech: Research Funding; De Novo Biopharma: Research Funding; AstraZeneca: Consultancy; Millenium/Takeda: Consultancy; Beigene: Consultancy; Bayer: Research Funding; AstraZeneca: Research Funding; Acerta Pharma BV: Research Funding; Karyopharm: Consultancy. Cheah:Celgene, F. Hoffmann-La Roche, Abbvie, MSD: Research Funding; Celgene, F. Hoffmann-La Roche, MSD, Janssen, Gilead, Ascentage Pharma, Acerta, Loxo Oncology, TG therapeutics: Honoraria. El-Galaly:F. Hoffmann-La Roche: Current Employment, Other: Support of parent study and funding of editorial support. Evens:Research To Practice: Honoraria, Speakers Bureau; Mylteni: Consultancy, Honoraria; Seattle Genetics: Consultancy, Honoraria, Research Funding; Pharmacyclics: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Merck: Consultancy, Honoraria, Research Funding; Epizyme: Consultancy, Honoraria, Research Funding; MorphoSys: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria.

BackgroundHidden hunger (micronutrient deficiencies) among adolescents are linked to impaired physical growth, poor cognitive function, low resistance to infection as well as degenerative and chronic diseases at later age. To prevent these deleterious impacts of hidden hunger, effective intervention strategy that improves nutrition knowledge and promotes healthy food choices among this age-group becomes imperative. The intervention was to evaluate the impact of a 14-page locally developed nutrition education aids on the teenagers’ knowledge of the functions, food sources and deficiencies of some micronutrients and their food choices.MethodsA one group pre-and post-intervention quasi-experimental study design was conducted with 869 adolescents (13–17 years) selected using multi-stage sampling technique in public secondary schools in a suburb of Nigeria. Using the instructional material development guidelines, the nutrition education aids were developed with nutrition facts, pictures of staple micronutrients-rich foods, and computer graphics. Baseline (pre-intervention) knowledge of nutrition and practice of food choices in relation to micronutrients were determined before exposing the students to the developed nutrition education aids and reassessing (post-intervention) them after 6 months. Data obtained were subjected to paired samples t-test using SPSS version 21.ResultsThe adolescents were mostly females (58.92%) aged 16–17 years (53.62%). There was significantly (p p ConclusionThe intervention strategy increased the nutrition knowledge and the consumption of some micronutrients-rich food sources among the adolescents. The developed nutrition education aids are recommended for use in the fight to reduce/eradicate hidden hunger among adolescents in Nigeria.

Introduction Pharmacotherapy to lower intraocular pressure (IOP) is a mainstay of treatment aimed at delaying progression of visual field loss in ocular hypertension (OHT) and open-angle glaucoma (OAG), but some topical treatments are less effective in controlling IOP at night. Peak IOP may be related to glaucoma progression and can occur outside office hours. A phase 2 study was conducted to evaluate the IOP-lowering efficacy of netarsudil across the diurnal and nocturnal periods. Methods This was a randomized, double-masked, single-center, vehicle-controlled, 9-day study. After washout of any prior ocular hypotensive agents, 12 patients with OHT or OAG underwent baseline IOP assessment at 15:00, 18:00, 21:00, 00:00, 03:00, 06:00, 09:00, and 12:00 h on day 1/day 2. Participants were then randomized in a 2:1 ratio to netarsudil ophthalmic solution 0.02% (n = 8) or vehicle (n = 4) for 7 days of self-administered dosing each evening. IOP was assessed at the same time points on day 8/day 9. All measurements were conducted with a Perkins tonometer in habitual positions by day (seated) and at night (supine). Results Baseline mean 24-h IOP was 22.4 mmHg in the netarsudil group and 22.9 mmHg in the vehicle group. Netarsudil was associated with a reduction in mean nocturnal IOP (measurements at 21:00, 00:00, 03:00, 06:00 h) of 3.5 mmHg, which was significant relative to baseline nocturnal IOP (P, Plain Language Summary When pressure inside the eye (called intraocular pressure [IOP]) builds up, a patient may develop a condition known as glaucoma, in which damage to the optic nerve and possibly irreversible vision loss occur. Glaucoma can be preceded in some patients by a condition called ocular hypertension (OHT). Patients with OHT and the most common type of glaucoma (open-angle glaucoma [OAG]) should be treated to lower their IOP and decrease the risk for progressive visual loss. Several studies that have evaluated 24-h IOP control have indicated that some eye drops lower IOP less effectively at night than during the day. A pilot study was conducted in 12 patients with OHT or OAG to evaluate netarsudil’s IOP lowering effect during the day and at night. After a week of treatment with netarsudil or a similar eye drop that did not contain the active drug, patients who took netarsudil experienced the same decrease in IOP at night as during the day. IOP was statistically lower with netarsudil than with the drug-free comparator both during the day and at night. Although this was a small study in 12 patients, the results are of interest because they suggest that netarsudil might consistently reduce IOP over a 24-h period.

PURPOSE Burkitt lymphoma is an aggressive B-cell lymphoma curable with dose-intensive chemotherapy derived from pediatric leukemia regimens. Treatment is acutely toxic with late sequelae. We hypothesized that dose-adjusted etoposide, doxorubicin, cyclophosphamide, vincristine, prednisone, and rituximab (DA-EPOCH-R) may obviate the need for highly dose-intensive chemotherapy in adults with Burkitt lymphoma. METHODS We conducted a multicenter risk-adapted study of DA-EPOCH-R in untreated adult Burkitt lymphoma. Low-risk patients received three cycles without CNS prophylaxis, and high-risk patients received six cycles with intrathecal CNS prophylaxis or extended intrathecal treatment if leptomeninges were involved. The primary endpoint was event-free survival (EFS), and secondary endpoints were toxicity and predictors of EFS and overall survival (OS). RESULTS Between 2010 and 2017, 113 patients were enrolled across 22 centers, and 98 (87%) were high risk. The median age was 49 (range, 18-86) years, and 62% were ≥ 40 years. Bone marrow and/or CSF was involved in 29 (26%) of patients, and 28 (25%) were HIV positive. At a median follow-up of 58.7 months, EFS and OS were 84.5% and 87.0%, respectively, and EFS was 100% and 82.1% in low- and high-risk patients. Therapy was equally effective across age groups, HIV status, and International Prognostic Index risk groups. Involvement of the CSF identified the group at greatest risk for early toxicity-related death or treatment failure. Five treatment-related deaths (4%) occurred during therapy. Febrile neutropenia occurred in 16% of cycles, and tumor lysis syndrome was rare. CONCLUSION Risk-adapted DA-EPOCH-R therapy is effective in adult Burkitt lymphoma regardless of age or HIV status and was well tolerated. Improved therapeutic strategies for adults with CSF involvement are needed (funded by the National Cancer Institute; ClinicalTrials.gov identifier: NCT01092182 ).

Background ALK-rearrangement is observed in Case presentation A 76 year old ‘never smoker’ female with an ALK-rearranged left upper lobe T2 N0 NSCLC experienced a stroke following elective DC cardioversion for new atrial fibrillation. Following a good recovery, updated imaging demonstrated complete regression of the left upper lobe lesion and a reduction of the previously documented mediastinal lymph node. Remaining atelectasis was non-avid on repeat PET-CT imaging, 8 months from the baseline PET-CT. When the patient developed new symptoms 6 months later a further PET-CT demonstrated FDG-avid local recurrence. She completed 55 Gy in 20 fractions but at 18 months post-radiotherapy there was radiological progression in the lungs with new pulmonary metastases and effusion and new bone metastases. Owing to poor performance status, she was not considered fit for targeted therapy and died 5 months later. Conclusion All reported cases of spontaneous regression in lung cancer have been collated within. Documented precipitants of spontaneous regression across tumour types include biopsy and immune reconstitution; stroke has not been reported previously. The favourable response achieved with radical radiotherapy alone in this unusual case of indolent oncogenic NSCLC reinforces the applicability of radiotherapy in locally advanced ALK-rearranged tumours, in cases not behaving aggressively. As a common embolic event affecting the neurological and pulmonary vasculature is less likely, an immune-mediated mechanism may underpin the phenomenon described in this patient, implying that hitherto unharnessed principles of immuno-oncology may have relevance in oncogenic NSCLC. Alternatively, high electrical voltage applied percutaneously adjacent to the tumour during cardioversion in this patient may have induced local tumour cell lethality.

Peace Uwambaye,1 Cyprien Munyanshongore,2 Michael Kerr,3 Harlan Shiau,4 Gerard Nyiringango,5 Stephen Rulisa6 1Department of Preventive and Community Dentistry, School of Dentistry, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda; 2Department of Community Health, University of Rwanda College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda; 3Arthur Labatt Family School of Nursing, University of Western Ontario, London, ON, Canada; 4Department of Advanced Oral Sciences and Therapeutics, Division of Periodontics, University of Maryland School of Dentistry, Baltimore, MD, USA; 5Department of Nursing, School of Health Sciences, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda; 6Department of Obstetrics and Gynecology, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, RwandaCorrespondence: Peace UwambayeDepartment of Preventive and Community Dentistry, School of Dentistry, College of Medicine and Health Sciences, University of Rwanda, Kigali, RwandaTel +250788505856Email upeace1602@gmail.comIntroduction: Oral health is considered an important component of general health; the mouth cannot be considered in isolation from the rest of the body. Studies indicate an association between periodontitis and preterm and lowbirth weight outcomes. One of the opportunities to improve the oral health care of pregnant women during antenatal care consultations is through collaboration with nurses and midwives. It can be of importance if nurses/midwives are equipped with the right knowledge, attitude and practices regarding oral health. Therefore, this study assessed the existing knowledge, attitude and practices of nurse/midwives working in antenatal clinics in 12 selected health facilities in the Southern Province of Rwanda on periodontal diseases.Patients and Methods: A descriptive cross-sectional study was done on 79 nurses and midwives working at antenatal care clinics and maternity wards. An ANOVA test was used to compare knowledge, attitude and practices mean scores of nurses/midwives about periodontal diseases and their management. A correlation test was also used to ascertain the relationship among knowledge, attitude, practices and other continuous variables.Results: The average age of nurses/midwives was M=33.57, SD=6.1. Nurses had limited knowledge about oral health of pregnant women and had some misunderstandings about oral health, although they had good attitudes. Age, length of service as a nurse or midwife and length of service in antenatal care had no effect on the knowledge, practice and attitude scores of the nurses/midwives. The ANOVA test did not find any significant difference in means for knowledge, attitude, practice and education level (p=0.69, 0.93, 0.27), respectively.Conclusion: Although nurses/midwives have good attitude regarding the management of periodontal diseases of pregnant women, their knowledge is insufficient and it is highly recommended that oral diseases can be included in their curriculum so that they can be in the best position to advise/screen for periodontal diseases during pregnancy.Keywords: knowledge, attitude, practice, oral health, pregnancy

Herpes simplex virus type 2 (genital herpes) is mostly asymptomatic except if the immune system is compromised. However, infections could lead to preterm delivery, low infant birth weight, still birth, hydrops, cystic brain degeneration, and fetal growth retardation. Record of the prevalence of the viral infection is scanty among pregnant women in Ekiti State, Nigeria. This study was conducted to determine the prevalence of herpes simplex virus type 2 antibodies among pregnant women attending Federal Teaching Hospital Ido-Ekiti. Structured questionnaires were administered to obtain information such as age, incidence of miscarriages, marital status and number of pregnancies among the women who were examined. Ninety (90) pregnant women were examined for the presence of herpes simplex virus type 2 (HSV-2) IgG and IgM antibodies using enzyme linked immunosorbent assay (ELISA) technique. Prevalence of HSV-2 IgG and IgM antibodies among pregnant women was 64.4 % and 2.2 % respectively. A significant (p0.05) difference between the prevalence of HSV-2 IgG antibody across age ranges, number of miscarriages, marital status and number of pregnancies. There may be need for antenatal screening of pregnant women for this virus in Ekiti State and perhaps generally in pregnancy to rule out the presence of genital herpes. With the risk of infection to fetus in mind, health policy makers may campaign against genital herpes to avert transmission of the virus to fetus before birth or after child birth.

Purpose AE37 and GP2 are HER2 derived peptide vaccines. AE37 primarily elicits a CD4+ response while GP2 elicits a CD8+ response against the HER2 antigen. These peptides were tested in a large randomized trial to assess their ability to prevent recurrence in HER2 expressing breast cancer patients. The primary analyses found no difference in 5-year overall disease-free survival (DFS) but possible benefit in subgroups. Here, we present the final landmark analysis. Methods In this 4-arm, prospective, randomized, single-blinded, multi-center phase II trial, disease-free node positive and high-risk node negative breast cancer patients enrolled after standard of care therapy. Six monthly inoculations of vaccine (VG) vs. control (CG) were given as the primary vaccine series with 4 boosters at 6-month intervals. Demographic, safety, immunologic, and DFS data were evaluated. Results 456 patients were enrolled; 154 patients in the VG and 147 in CG for AE37, 89 patients in the VG and 91 in CG for GP2. The AE37 arm had no difference in DFS as compared to CG, but pre-specified exploratory subgroup analyses showed a trend towards benefit in advanced stage (p = 0.132, HR 0.573 CI 0.275–1.193), HER2 under-expression (p = 0.181, HR 0.756 CI 0.499–1.145), and triple-negative breast cancer (p = 0.266, HR 0.443 CI 0.114–1.717). In patients with both HER2 under-expression and advanced stage, there was significant benefit in the VG (p = 0.039, HR 0.375 CI 0.142–0.988) as compared to CG. The GP2 arm had no significant difference in DFS as compared to CG, but on subgroup analysis, HER2 positive patients had no recurrences with a trend toward improved DFS (p = 0.052) in VG as compared to CG. Conclusions This phase II trial reveals that AE37 and GP2 are safe and possibly associated with improved clinical outcomes of DFS in certain subgroups of breast cancer patients. With these findings, further evaluations are warranted of AE37 and GP2 vaccines given in combination and/or separately for specific subsets of breast cancer patients based on their disease biology.

Supplemental Digital Content is available in the text., Objectives: Timely prehospital diagnosis and treatment of acute coronary syndrome (ACS) are required to achieve optimal outcomes. Clinical decision support systems (CDSS) are platforms designed to integrate multiple data and can aid with management decisions in the prehospital environment. The review aim was to describe the accuracy of CDSS and individual components in the prehospital ACS management. Methods: This systematic review examined the current literature regarding the accuracy of CDSS for ACS in the prehospital setting, the influence of computer-aided decision-making and of 4 components: electrocardiogram, biomarkers, patient history, and examination findings. The impact of these components on sensitivity, specificity, and positive and negative predictive values was assessed. Results: A total of 11,439 articles were identified from a search of databases, of which 199 were screened against the eligibility criteria. Eight studies were found to meet the eligibility and quality criteria. There was marked heterogeneity between studies which precluded formal meta-analysis. However, individual components analysis found that patient history led to significant improvement in the sensitivity and negative predictive values. CDSS which incorporated all 4 components tended to show higher sensitivities and negative predictive values. CDSS incorporating computer-aided electrocardiogram diagnosis showed higher specificities and positive predictive values. Conclusions: Although heterogeneity precluded meta-analysis, this review emphasizes the potential of ACS CDSS in prehospital environments that incorporate patient history in addition to integration of multiple components. The higher sensitivity of certain components, along with higher specificity of computer-aided decision-making, highlights the opportunity for developing an integrated algorithm with computer-aided decision support.

The study determined the prevalence of non-adherence to medication, self monitoring of blood glucose (SMBG), clinic visits and the associated factors among out-patient type 2 adult diabetics at a tertiary hospital in Enugu State Nigeria. Using a descriptive cross-sectional design, 200 patients was purposively selected. Researcher-developed questionnaire was tool for data collection. Analysis was done in proportions, percentages and logistic regression (alpha level was P=0.05). Respondents’ mean age was 60.1±10.6; 88% were married and females were 63.5%. Overall prevalence of non adherence to drugs was 24.5%; that varied from 26.9 to 11.8% depending on drug combinations. Majority (57.5%) of the respondents had no glucometer for SMBG at home; 86.1% on oral hypoglycaemic agents did not monitor their blood glucose level 2-3 times weekly; 78.9% on injection insulin combined with tablets did not monitor their blood glucose level at least once daily. Non-adherents to clinic visits were 49.0%. Age

The optimal application of gamified methods in the teaching of Physiology requires research, as evidence on its impact is rudimentary. The purpose of this study was to determine the effects of gamification on learner attitudes, student performance scores, and brainwave activity in a Physiology learning environment. A cohort of 14 students from the first year Bachelor of Clinical Medical Practice program were randomly assigned to the gamified (G) and non-gamified (N-G) groups. The G group participated in a gamified activity, while the N-G group participated in a didactic teaching setting. The students were assessed on the same content. Electroencephalogram (EEG) recordings were measured using a MyndBand device during student participation in the assigned activities. Software algorithms computed attention and meditation brainwave signals that had been recorded during the testing sessions. The results of the study revealed higher performance scores in the G group when compared to the N-G group. Results also showed a higher median brainwave activity for attention signals in the G than in the N-G group. There was a positive correlation between median attention signals and performance scores. These preliminary findings on the use of gamification in a Physiology classroom setting indicate an improved cognitive outcome that is substantiated by the EEG brainwave attention signals.

Children with mild to moderate chronic kidney disease are at an increased risk for cardiovascular sequelae, the leading cause of death in children with end-stage renal disease. We aimed to establish the prevalence of aortic dilatation, a newly recognized cardiovascular sequelae of renal disease, within a cohort of pediatric patients with mild to moderate kidney disease. A total of 501 children enrolled in the Chronic Kidney Disease in Children study contributed imaging data between April 2011 and February 2015. Aortic dilatation was defined as a dimension exceeding a z-score of 2 at any of three locations: aortic root, sinotubular junction, or the ascending aorta. At baseline echocardiographic evaluation, 30 (6%) children were identified to have aortic dilatation in at least one of the three locations. Multivariate analysis demonstrated an increased odds ratio for the presence of aortic dilatation associated with the following variables: high diastolic blood pressure z-scores, low weight z-score, and low body mass index z-score. Presense of protein energy wasting (modified definition, OR 2.41, 95%CI 1.23, 4.70) was the strongest independent predictor of aortic dilatation. In conclusion, aortic dilatation does occur early in the course of chronic kidney disease and associates with markers of poor nutrition. Future studies should continue to evaluate these risk factors longitudinally as the kidney disease progresses.

ObjectivesMortality during acute illness among children in low- and middle-income settings remain unacceptably high and there is increasing recognition of the importance of post-discharge mortality. A comprehensive understanding of pathways underlying mortality among acutely ill children is needed to develop interventions and improve guidelines. We aimed to determine the incidence, timing and contributions of proximal and underlying exposures for mortality among acutely ill young children from admission to hospital until 6 months after discharge in sub-Saharan Africa and South Asia in the context of guideline-based care.DesignA prospective stratified cohort study recruiting acutely ill children at admission to hospital with follow up until 180 days after discharge from hospital (November 2016-July 2019).SettingNine urban and rural hospitals in sub-Saharan Africa and South Asia across a range of facility levels, and local prevalences of HIV and malaria.ParticipantsInclusion criteria were age 2-23 months, admission to hospital with acute, non-traumatic medical illness and stratified into three groups by anthropometry. Children were excluded if currently receiving pulmonary resuscitation, had a known condition requiring surgery within 6 months or known terminal illness with death expected within 6 months.Main outcome measuresAcute mortality occurring within 30-days from admission; post-discharge mortality within 180-days from discharge; characteristics with direct and indirect associations with mortality within a multi-level a priori framework including demographic, clinical, anthropometric characteristics at admission and discharge from hospital, and pre-existing child-, caregiver- and household-level characteristics.ResultsOf 3101 participants (median age 11 months), 1218 were severely wasted/kwashiorkor, 763 moderately wasted and 1120 were not wasted. Of 350 deaths, 182 (52%) occurred during index admission, 234 (67%) within 30-days of admission and 168 (48%) within 180-days post-discharge. Ninety (54%) post-discharge deaths occurred at home. The ratio of inpatient to post-discharge mortality was consistent across anthropometric strata and sites. Large high and low risk groups could be disaggregated for both early and post-discharge mortality. Structural equation models identified direct pathways to mortality and multiple socioeconomic, clinical and nutritional domains acting indirectly through anthropometric status.ConclusionsAmong diverse sites in Africa and South Asia, almost half of mortality occurs post-discharge. Despite being highly predictable, these deaths are not addressed in current guidelines. A fundamental shift to a risk-based approach to inpatient and post-discharge management is needed to further reduce childhood mortality and clinical trials of these approaches with outcomes of mortality, readmission and cost are warranted.Trial RegistrationClinicalTrials.gov: NCT03208725

Introduction Our study analyses the influence of the COVID-19 pandemic on perioperative death in elderly patients undergoing surgery for fractures who test positive for the virus during their admission in a rural hospital setting in the UK. Methods One hundred and fifty-six consecutive patients with age more than 75 years, who underwent surgery for fractures in Glangwili General Hospital during the second wave of the pandemic between 20th November 2020 and 20th January 2021, were included in this study. The 28-day mortality rate was estimated, and the results were compared to a matched cohort of patients from a similar duration before the pandemic (20th November 2019 to 20th January 2020). Results A total of 41 out of 156 patients were tested positive for COVID-19 in this study cohort. The overall 28-day mortality rate was 8.9% (n=15 patients) in comparison to 4% (n=8) in the comparative cohort of 196 patients from the pre-pandemic era. Of the 41 patients who tested positive for COVID-19, 11 patients died within 28 days of surgery, resulting in a mortality rate of 26.8% with a relative risk of 7.7(p=0.0461). Furthermore, 91% (n=10) of COVID-19-positive patients who died had an underlying cardiac disease and/or proximal femoral fractures. The 28-day mortality rate in those tested negative for COVID-19 was 3.5% (n=4). Conclusion There is a significantly increased risk of death in the perioperative period on contracting COVID-19, in patients who are 75 years of age or older, especially those with associated cardiac comorbidities and who have sustained proximal femoral fractures.

Introduction Treatment urgency of myocardial infarction (MI) is currently stratified by ST elevation (STEMI) or lack of ST elevation (NSTEMI) on the electrocardiogram. This categorisation arose from the theory that ST elevation indicated total acute coronary artery occlusion (1). However, one-quarter of all NSTEMI have acute occlusion, have a higher mortality and are potentially missed by this strategy (2). Purpose The study purpose is to identify clinical features that could help distinguish an occlusive MI from non-occlusive MI. Methods The prospectively British Cardiovascular Intervention Society (BCIS) data set was collected from patients undergoing primary cutaneous intervention (dataset) was analysed from the years 2015 to 2019. Data collected included presentation characteristics, co-morbidities, treatments and outcomes. We further undertook latent class analysis, to determine whether distinct patterns of presentation and history are associated with acutely occluded NSTEMI. This methodology proceeds through segmentation of a dataset into clusters (“classes”) based on case similarities for the set of variables or “indicators” of interest; the classes are then statistically analysed to evaluate the differences between them. Results A total of 2025 patients underwent percutaneous coronary intervention (PCI) between 2015 and 2019. Of these, 1412 underwent PCI for MI, 510 had a STEMI, and 263 had occlusive MI on angiogram. STEMI patients tended to be younger (66 vs 67; p=0.045), in shock (6.1% vs 1.9%; p Conclusion Features between occlusive MI and STEMI are broadly very similar. However, unlike STEMI/NSTEMI, there was no difference in age and risk of cerebrovascular disease in the occlusive MI/non-occlusive MI group. This could indicate occlusion MI occurs in higher numbers in elderly and frail patients and may be frequently missed, possibly from greater collateralisation. There is no reliable characteristic for identifying occlusive between non-occlusive MI. Improved methods are needed for the identification of occlusive MI patients. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): A project supported by the European Union's INTERREG VA Programme, managed by the Special EU Programmes Body (SEUPB). The funders of this project had no input in designing, implementation or writing of this review. Step 1 of latent class analysis

Coronary artery disease (CAD) is a pathological process characterized by atherosclerotic plaque accumulation in the epicardial arteries, whether obstructive or non-obstructive. This process can be modified by lifestyle adjustments, pharmacological therapies, and invasive interventions designed to achieve disease stabilization or regression. The disease can have long, stable periods but can also become unstable at any time, typically due to an acute atherothrombotic event caused by plaque rupture or erosion. However, the disease is chronic, most often progressive, and hence serious, even in clinically apparently silent periods. The dynamic nature of the CAD process results in various clinical presentations, which can be conveniently categorized as either acute coronary syndromes (ACS) or chronic coronary syndromes (CCS). The Guidelines presented here refer to the management of patients with CCS. The natural history of CCS is illustrated in Figure 1.

Background The prevalence of chronic kidney disease is on the rise globally and in sub-Saharan Africa. Due to its “silent” nature, many patients often present with advanced disease. At this point options for care are often limited to renal replacement therapies such as hemodialysis and kidney transplantation. In resource limited settings, these options are associated with catastrophic expenditures and increased household poverty levels. Early palliative care interventions, if shown to ensure comparable quality of life (QoL), can significantly mitigate this by focusing care on comfort, symptom control and QoL rather than primarily on prolonging survival. Methods A mixed methods longitudinal study, recruiting patients with End Stage Renal Disease (ESRD) on hemodialysis or conservative management and following them up over 12 months. The study aims are to: 1) measure and compare the health-related quality of life (HRQoL) scores of patients with ESRD receiving hemodialysis with those receiving conservative management, 2) measure and compare the palliative care needs and outcomes of patients in the two groups, 3) explore the impact of treatment modality and demographic, socio-economic and financial factors on QoL and palliative care needs and outcomes, 4) review patient survival over 12 months and 5) explore the patients’ lived experiences. The Kidney Disease Quality Of Life Short Form version 1.3 (KDQOL-SF) will be used to measure HRQoL; the African Palliative Care Association Palliative care Outcome Score (APCA POS) and the Palliative care Outcome Score for renal symptoms (POS-S Renal) will be used to assess palliative care needs and outcomes; and semi-structured in-depth interviews to explore the patients’ experiences of living with ESRD. Data collection will be carried out at 0, 3, 6, 9 and 12 months. Discussion To the best of our knowledge, no similar study has been conducted in sub-Saharan Africa. This will be an important step towards raising awareness of patients’ need and preferences and the strengths and limitations of available health care services for ESRD in resource limited settings.

Objectives: Anti-police (#EndSARS) protests took place in October 2020 across several Nigerian cities, resulting in deaths, injuries and loss of property, but the psychological sequelae of these protests have not been studied. Method: In a cross-sectional online survey, we collected data on psychiatric morbidity and potential risk factors from 426 Nigerian social media users, who self-identified as participants or non-participants in a recent anti-police protest. Results: We found elevated rates of psychiatric morbidity, with worse outcomes for protesters compared to non-protesters (psychological distress [44.2% vs 29.8%], depression [26.0% vs 14.9%], anxiety [51.0% vs 29.8%], post-traumatic stress disorder [7.4% vs 1.8%], current substance use [11.2% vs 4.5%] and suicidal ideation [7.1% vs 4.4%], respectively). After adjusting for the effects of COVID-19 pandemic and previous mental health diagnosis, the predictors of poor mental health among non-protesters were being unmarried (odds ratio = 7.4, p = 0.01) and low resilience (odds ratio range = 4.1–5.4, p Conclusion: We conclude that participating in the #EndSARS protest was associated with significant psychiatric morbidity. There is need to recognise and address the mental health sequelae of collective actions, and invest in programmes that build resilience and address socio-political determinants of mental health, especially with a focus on youth.

Background: Malaria in pregnancy is a major public health problem in sub-Saharan Africa and can result in placental malaria with its associated adverse pregnancy outcomes.Method: This was a case control study involving 190 consenting, asymptomatic, booked parturients, recruited consecutively at 36 week. The aim was to determine the effect of placental malaria on pregnancy outcome in asymptomatic women delivering at term. The participants were screened for malaria parasites using peripheral blood film. Based on their results, the participants were grouped into parasitemia positive cases (Group 1) and parasitemia negative controls (Group 2). Both groups were then followed up in the clinic till they presented in labour at term. In labour, participants’ peripheral venous blood sample were collected and used to determine intrapartum haematocrit and peripheral parasitemia. After delivery, cord blood and a section of the placenta were collected for investigation. Data analysis: Collected data were analysed using Statistical Product and service solutions (SPSS) software (version 20). Numerical variables were presented as mean and standard deviation (Mean SD), while categorical variables were presented as numbers and percentages. Chi-square test(X2) was used to compare qualitative variables. Odds ratio (OR) and Confidence interval(CI) were used to observe the odds of outcomes. A p-value 0.05 was considered statistically significant.Results: The prevalence of placental malaria and congenital malaria were 41.05% and 29.47% respectively. Birth weight, APGAR score, NICU admission or congenital malaria were not statistically significant between the two groups. The mean birth weight was 3.16 ± 0.5 kg while 17.89% had low birth weight. There was also no significant difference between the two groups in terms of the association of placental parasitaemia and maternal anaemia or dose of IPT taken. There was no significant association between placental parasitaemia and low parity. Multivariate logistic regression analysis of maternal anaemia and low birth weight showed significant placental parasitaemia in both cases (p = 0.004). Conclusion: Placental parasitaemia is a major complication of malaria in pregnancy and is associated with adverse feto-maternal effects. Early booking and uptake of intermittent preventive therapy with sulphadoxine-pyrimethamine may help reduce the adverse effects.

INTRODUCTION AND OBJECTIVE:Lower urinary tract symptoms due to benign prostatic hyperplasia (BPH) are common. Per the American Urologic Association guidelines, there are two prostate size-independe...

Background Inpatient health care facilities restricted inpatient visitation due to the COVID-19 pandemic. There is no existing evidence of how they communicated these policies to the public nor the impact of their communication choices on public perception. Objective This study aims to describe patterns of inpatient visitation policies during the initial peak of the COVID-19 pandemic in the United States and the communication of these policies to the general public, as well as to identify communication strategies that maximize positive impressions of the facility despite visitation restrictions. Methods We conducted a sequential, exploratory, mixed methods study including a qualitative analysis of COVID-19 era visitation policies published on Pennsylvania-based facility websites, as captured between April 30 and May 20, 2020 (ie, during the first peak of the COVID-19 pandemic in the United States). We also conducted a factorial survey-based experiment to test how key elements of hospitals’ visitation policy communication are associated with individuals’ willingness to seek care in October 2020. For analysis of the policies, we included all inpatient facilities in Pennsylvania. For the factorial experiment, US adults were drawn from internet research panels. The factorial survey-based experiment presented composite policies that varied in their justification for restricted visitation, the degree to which the facility expressed ownership of the policy, and the inclusion of family-centered care support plans. Our primary outcome was participants’ willingness to recommend the hypothetical facility using a 5-point Likert scale. Results We identified 104 unique policies on inpatient visitation from 363 facilities’ websites. The mean Flesch-Kincaid Grade Level for the policies was 14.2. Most policies prohibited family presence (99/104, 95.2%). Facilities justified the restricted visitation policies on the basis of community protection (59/104, 56.7%), authorities’ guidance or regulations (34/104, 32.7%), or scientific rationale (23/104, 22.1%). A minority (38/104, 36.5%) addressed how restrictive visitation may impair family-centered care. Most of the policies analyzed used passive voice to communicate restrictions. A total of 1321 participants completed the web-based survey. Visitation policy elements significantly associated with willingness to recommend the facility included justifications based on community protection (OR 1.44, 95% CI 1.24-1.68) or scientific rationale (OR 1.30, 95% CI 1.12-1.51), rather than those based on a governing authority. The facility expressed a high degree of ownership over the decision (OR 1.16, 95% CI 1.04-1.29), rather than a low degree of ownership; and inclusion of family-centered care support plans (OR 2.80, 95% CI 2.51-3.12), rather than no such support. Conclusions Health systems can immediately improve public receptiveness of restrictive visitation policies by emphasizing community protection, ownership over the facility’s policy, and promoting family-centered care.

Food Safety is of growing concern globally, and more so considering the relatively high proportion of soft drinks in the beverage market worldwide, and its rate of consumption especially amongst the youths. It is essential to evaluate the levels of toxic metals and Polycyclic Aromatic Hydrocarbons (PAHs) residues of which when present in soft drinks above the permissible limits could pose serious public health risk. The aim of this present study was to assess the levels of heavy metals (Pb, Hg, Cd ,As) and Polycyclic aromatic Hydrocarbons(PAHs) in 16 commercial soft drinks marketed in Awka, using Atomic Absorption Spectroscopy(AAS) and Flame Ionization detector (GC-FID), respectively. The objective of the study was to evaluate the potential human risk indices of heavy metals and polyaromatic hydrocarbons in the studied beverages. The carcinogenic and non-carcinogenic risk assessment were performed using the method established by United State Environmental Protection agency(USEPA).The data obtained were compared with the permissible limit set for drinking water by United State Environmental Protection Agency(USEPA),World Health Organization (WHO),Standard Organization of Nigeria(SON) and Federal Environmental Protection Agency(FEPA). The highest mean level of 0.6116 mg/l is related to Pb and the lowest of 0.0028mg/l related to Hg. The mean levels of the metals increased in this order: Hg 1, and thus, pose a health risk. The hazard index, calculated as the combined risk of heavy metal toxicity is greater than unity (HI>1).The incremental lifetime cancer risk (ILCR) values estimated for Pb, As and Cd in the sample were 6.25%,31.25% and 25% ,respectively, rep- resenting higher than acceptable risk value of (10-6 -10-4) . The results raise a concern for the public exposed with respect to As and Cd carcinogenic risk values.

ObjectivesRetinopathy of prematurity (ROP) will become a major cause of blindness in Nigerian children unless screening and treatment services expand. This article aims to describe the collaborative activities undertaken to improve services for ROP between 2017 and 2020 as well as the outcome of these activities in Nigeria.DesignDescriptive case study.SettingNeonatal intensive care units in Nigeria.ParticipantsStaff providing services for ROP, and 723 preterm infants screened for ROP who fulfilled screening criteria (gestational age Methods and analysisA WhatsApp group was initiated for Nigerian ophthalmologists and neonatologists in 2018. Members participated in a range of capacity-building, national and international collaborative activities between 2017 and 2018. A national protocol for ROP was developed for Nigeria and adopted in 2018; 1 year screening outcome data were collected and analysed. In 2019, an esurvey was used to collect service data from WhatsApp group members for 2017–2018 and to assess challenges in service provision.ResultsIn 2017 only six of the 84 public neonatal units in Nigeria provided ROP services; this number had increased to 20 by 2018. Of the 723 babies screened in 10 units over a year, 127 (17.6%) developed any ROP; and 29 (22.8%) developed type 1 ROP. Only 13 (44.8%) babies were treated, most by intravitreal bevacizumab. The screening criteria were revised in 2020. Challenges included lack of equipment to regulate oxygen and to document and treat ROP, and lack of data systems.ConclusionROP screening coverage and quality improved after national and international collaborative efforts. To scale up and improve services, equipment for neonatal care and ROP treatment is urgently needed, as well as systems to monitor data. Ongoing advocacy is also essential.

Diffuse large B-cell lymphoma featuring overexpression of MYC and B-Cell Lymphoma 2 (double expressor lymphoma, DEL) is associated with poor outcomes. Existing evidence suggesting improved outcomes for DEL with the use of more intensive regimens than R-CHOP is restricted to younger patients and based on limited evidence from low patient numbers. We retrospectively evaluated the impact of intensive frontline regimens versus R-CHOP in a multicenter analysis across 7 academic medical centers in the United States. We collected 90 cases of DEL, 46 out of 90 patients (51%) received R-CHOP and 44/90 (49%) received an intensive regimen, which was predominantly DA-EPOCH-R. Treatment cohorts were evenly balanced for demographics and disease characteristics, though the intensive group had a higher lactate dehydrogenase (LDH, 326 vs. 230 U/L p = 0.06) and presence of B-symptoms (50% vs. 22%, p = 0.01) compared to the R-CHOP cohort. There was no difference in PFS (median 53 vs. 38 months, p = 0.49) or overall survival (67 vs. not reached months, p = 0.14) between the R-CHOP and intensive therapy cohorts, respectively. On multivariate analysis, intensive therapy was associated with a hazard ratio of 2.35 (95% CI 0.74-7.41), though this was not statistically significant. Additionally, a subgroup analysis of intermediate high-risk lymphoma defined by IPI ≥3 did not identify a difference in survival outcomes between regimens. We conclude that in our multi-center cohort there is no evidence supporting the use of intensive regimens over R-CHOP, suggesting that R-CHOP remains the standard of care for treating DEL.

Williams syndrome is a multisystem, congenital disorder which is commonly associated with arterial stenoses: supravalvar aortic stenosis and peripheral pulmonary artery stenosis. Venous abnormalities have not been previously reported in children with Williams syndrome. We present a case of a 3-year-old girl with Williams syndrome and diffuse venous ectasia as detected by MRI.

Substantial evidence indicates that adolescents and young adults have a disproportionately high incidence of most forms of violence, including suicide. Suicidality often includes suicidal ideation. The present study examined the relationship between bullying and suicidal ideation, and further tested whether social support moderates the association between the dimensions of bullying (verbal bullying, physical bullying, and bullying victimization) and suicidal ideation among adolescent secondary school students. A cross-sectional design was adopted for the study. Participants were 394 students (249 boys, 145 girls) drawn from two secondary schools in Nsukka semi-urban area, in southeast Nigeria. Participants completed the Illinois Bully Scale, the Columbia-Suicide Severity Rating Scale, and the Multidimensional Scale of Perceived Social Support (MSPSS). Hayes’ regression-based PROCESS macro was used to analyze the data. Verbal bullying, physical bullying, and victimization were independently positively associated with suicidal ideation. Social support was not independently significantly associated with suicidal ideation, but it moderated the relationship between victimization and suicidal ideation. The positive relationship between victimization and suicidal ideation was strongest for adolescents who had low social support, compared to those who had moderate or high social support. This finding is consistent with the buffering hypothesis of social support, suggesting that supportive relationships for victims can mitigate suicidal ideation.

Aspirin non-response is associated with poor outcome but there is no agreement between the different methods to asses it. Weight has been shown to be a predictor of poor response but only using one method. In this study, we determine the effects of weight on different assays of platelet function. The response to aspirin was determined in 138 cardiology patients using serum thromboxane, arachidonic acid-induced platelet aggregation and VerifyNow©. Twenty-five percent of patients showed an inadequate response to aspirin in at least one assay on the initial test. After ensuring patient compliance only 5% of patients were considered to be non-responders. Only 9% of non-responders were non-responsive in all three assays. When switched to plain aspirin, only 2% of patients were non-responsive. All patients responded adequately to 150 mg aspirin. The non-responders were significantly heavier than responders (78.5 kg ± 14.0 (SD); BMI: 28.4 kg/m2± 4.4 v's 102.6 kg ± 20.6, P = .0016; BMI: 38.3 kg/m2 ± 7.6, P= .0015). A rule-based approach of using plain aspirin in patients over 90 kg or BMI 32 along with patient education to ensure compliance will ensure that all patients respond to their aspirin without the need for testing.

Background Gut microbiota play an important role in human health. However, the application of gut microbiome in regular clinical practice is limited by interindividual variations and complexity of test results. Hypothesis It is possible to address interindividual variation by using large data-based exploratory-pattern analysis. Methods The current study was conducted using a large data set (n = 173,221) of nonselective incoming patients’ test results from a stool test. The data set included assays for the detection of 24 selected commensal microorganisms and multiple biomarkers in feces. Patients were grouped based on their levels of inflammation biomarkers such as calprotectin, eosinophil protein X, and IgA. Group mean values of biomarkers and commensal microbes were used in an exploratory-pattern analysis for association from which an index score for intestinal inflammation-associated dysbiosis (IAD) was developed. The IAD score was evaluated in one questionnaire-based study (n = 7263) and one prospective case series study (n = 122) with patients of inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), and celiac disease. Results We identified a microbial profile strongly associated with fecal inflammation biomarkers. Developed on the pattern of the microbial profile, the IAD score demonstrated a strong association with fecal inflammation biomarkers and was significantly different between patients with IBD and those with IBS or celiac disease. Conclusion Using real-world data, we have developed a method to predict gut dysbiosis associated with different GI disease conditions. It may help clinicians simplify the process of interpreting gut microbial status and provide gut health assessment and treatment evaluation. Electronic supplementary material The online version of this article (10.1007/s10620-019-05828-8) contains supplementary material, which is available to authorized users.