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This case describes an atypical cutaneous presentation of metastatic gastric carcinoma in a patient initially presenting with dysphagia and a sclerotic red plaque overlying the anterior neck and chest. Skin biopsy revealed metastatic adenocarcinoma from the upper gastrointestinal tract. Esophagogastroduodenoscopy revealed stage IV metastatic gastric adenocarcinoma. Treatment with chemotherapy was initiated.

This case describes a patient with known mantle cell lymphoma without cutaneous involvement presenting with a diffuse morbilliform rash during an inpatient admission for bacterial pneumonia. The patient was thought to have a hypersensitivity to antibiotics but failed to improve after the offending agents were stopped. A skin biopsy revealed metastatic cutaneous mantle cell lymphoma. Treatment with high-dose corticosteroids and chemotherapy was initiated resulting in the resolution of the rash.

Abstract High extracellular matrix (ECM) content in solid cancers impairs tumour perfusion and thus access of imaging and therapeutic agents. We have devised a new approach to degrade tumour ECM, which improves uptake of circulating compounds. We target the immune‐modulating cytokine, tumour necrosis factor alpha (TNFα), to tumours using a newly discovered peptide ligand referred to as CSG. This peptide binds to laminin–nidogen complexes in the ECM of mouse and human carcinomas with little or no peptide detected in normal tissues, and it selectively delivers a recombinant TNFα‐CSG fusion protein to tumour ECM in tumour‐bearing mice. Intravenously injected TNFα‐CSG triggered robust immune cell infiltration in mouse tumours, particularly in the ECM‐rich zones. The immune cell influx was accompanied by extensive ECM degradation, reduction in tumour stiffness, dilation of tumour blood vessels, improved perfusion and greater intratumoral uptake of the contrast agents gadoteridol and iron oxide nanoparticles. Suppressed tumour growth and prolonged survival of tumour‐bearing mice were observed. These effects were attainable without the usually severe toxic side effects of TNFα.

Introduction: Clinical practice education is an important curriculum in developing physiotherapy students to professionals. This curriculum is largely dependent on clinical educators. Although traits of effective clinical educators had been studied in Western population, it was unclear if the Asian population would yield similar traits. Hence, we studied perspectives of students and academic educators to identify top five core traits of an effective clinical educator. The findings will then help guide policy development for clinical educator training and development. Methods: A survey was circulated to physiotherapy students and academic educators through convenience sampling. We studied 16 traits – enthusiasm, availability, clarity, clinical competence / knowledge, feedback skills, organisational skills, professionalism, well prepared, scholarly activity, non-judgemental, respect students’ autonomy / independence, sincerity, listening skills, evidence-based practice, role model, and awareness of students’ learning needs. Results: The top five traits identified by students and academic educators were similar in four traits – clinical competency / knowledge, clarity, feedback skills, and enthusiasm, and differed in the choice of “non-judgemental” by students and “awareness of students’ learning needs” by academic educators. Interestingly, when the top six traits were considered instead of five, students and academic educators identified the same traits but in different ranked orders. Conclusion: The study found six common core traits of an effective clinical educator from the perspectives of students and academic educators. Continuing education development for clinical educators should focus on these six traits prior to other 10 sub-traits.

Mansoor M Aman,1 Yussr M Ibrahim,2 Merve Buluk Figueira,1 Ahish Chitneni,3 Ammar Mahmoud2 1Department of Anesthesiology, Division of Pain Medicine, Advocate Health, Oshkosh, WI, USA; 2Department of Anesthesiology, Division of Pain Medicine, Northern Light Eastern Maine Medical Center, Bangor, ME, USA; 3Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital - Columbia and Cornell, New York, NY, USACorrespondence: Mansoor M Aman, Interventional Pain Medicine, Advocate Aurora Health, 700 N. Westhaven Drive, Oshkosh, WI, 54904, USA, Email mansoor.aman@aah.orgPurpose: This retrospective review evaluates pain and patient-defined functional goal improvement utilizing bipolar peripheral nerve stimulation (PNS) in chronic neuropathic and nociceptive pain states.Patients and Methods: Our dataset includes 24 patients who underwent implantation of a permanent peripheral nerve stimulator from January 2018 through December 2022. A total of 29 leads were implanted amongst 24 patients, with 5 patients having leads at 2 different dermatomes. Fifteen leads were placed for primarily neuropathic pain, and 14 leads were placed for nociceptive pain. Inclusion criteria were the following: pain duration greater than 6 months, documented peri-procedural Numerical Pain Rating Scale (NPRS) and greater than 60 days follow-up post implant.Results: Data was collected and analyzed showing that 89.6% of implants at 6 months follow-up and 70% at 12 months follow-up achieved 50% or greater pain relief. A significant reduction in NPRS scores when comparing pre-procedure pain scores (Median = 7, n = 29) to 6-month follow-up data (Median = 2, n = 29), p< 0.001 with a large effect size, r = 0.61. Ninety-three percent of patients reported achieving their personal functional goal. Twelve of the fourteen (86%) leads implanted for primary nociceptive pain and fourteen of the fifteen (93%) leads implanted for neuropathic pain achieved ≥ 50% relief at 6 months. At twelve months, seven leads in each group provided ≥ 50% sustained pain relief. Of the 14 patients that were on opioids, 6 discontinued, while another 2 had a reduction in oral morphine milligram equivalents (MME) at the 12-month follow-up.Conclusion: This retrospective review demonstrates the potential clinical application of PNS in both nociceptive and neuropathic pain states. Further prospective studies are warranted to validate the effectiveness of PNS in the treatment of refractory nociceptive and neuropathic pain states.Keywords: peripheral nerve stimulation, neuromodulation, neuropathic pain, nociceptive pain, chronic pain

Abstract Background Noncommunicable diseases (NCDs) are public health threats globally and recognized impediments to socioeconomic development. This study aimed to identify the prevalence and clustering of NCDs risk factors among Bangladeshi men and women aged 20–59 years using nationally representative data. Methods This study was conducted in 82 rural, nonslum urban, and slum clusters across all eight administrative divisions of Bangladesh using multistage cluster sampling. A total of 4917 men and 4905 women aged 20–59 years were included in the study. Descriptive analyses were performed to report the prevalence and distribution of behavioral and clinical risk factors. Multivariable binary logistic regression was performed to identify factors associated with the coexistence of three or more NCD risk factors. Results The prevalence of tobacco use (any form), insufficient physical activity, inadequate fruit and vegetable consumption, overweight and obesity, and central obesity were 38.3%, 13.6%, 87.1%, 42.3%, and 36.0%, respectively. Furthermore, 21.9% and 4.9% participants had hypertension and self‐reported diabetes, respectively. Regarding the clustering of risk factors, 37.1% men and 50.8% women had at least three NCD risk factors. Only 3.0% men and 1.8% women reported no NCD risk factors. Age, place of residence, education, and wealth status were associated with the presence of at least three risk factors for both sexes. Conclusion Since a large proportion of Bangladeshi 20–59 years old population had multiple risk factors, population‐based programs with multisectoral approaches are essential to reduce NCDs among Bangladeshi women and men.

Introduction: Osteoporosis and low bone mass affect millions of people worldwide, leading to severe consequences ranging from disability to mortality. This study aimed to determine the prevalence and risk factors of osteoporosis among postmenopausal women in a district of Nepal. Methods: An analytical cross-sectional study involving postmenopausal women from Nuwakot, Dhading, and Rasuwa districts in Nepal was conducted at Trishuli Hospital, Nuwakot. Ethical approval was taken from the Institutional Review Board of Nepal Health Research Council (Reference number: 1768). The prevalence of osteoporosis was determined, and the associated factors were analyzed using multivariate logistic regression. Dual-Energy X-ray Absorptiometry (GE-Lunar Prodigy) was used to measure Bone Mineral Density (g/cm2) at the proximal femur and lumbar spine. Various factors related to osteoporosis were also analyzed. Results: There were 384 postmenopausal women and the prevalence of osteoporosis was 82 (21.35%; 95% CI: 17.25%-25.45%)e. The mean age of female with osteoporosis was 67.52±8.84 years and that without osteoporosis was 55.70±7.69 years (p

As the population ages and grows, health services must evolve in ways to offer versatile patient care, whilst improving patient outcomes and maintaining long-term economic viability. A facility assisting in the provision of such healthcare is the hybrid operating room (HOR): a specialised suite allowing simultaneous radiological and surgical diagnostics and therapeutics in a single episode of care. Versatile and customizable, the HOR is utilised by a broad range of subspecialties in elective and emergency settings, including (but not limited to) vascular surgery, trauma surgery and interventional radiology. Though the benefits of hybrid techniques to patient care are well known, the actual steps in operationalising the HOR can be challenging if not considered and coordinated appropriately. The intention of this narrative review is to highlight issues and suggest solutions in the design and commissioning of an HOR. Key areas in need of specific attention include stakeholder involvement, economic feasibility, suite location, workflow planning, hybrid equipment choice, and team organisation.

Summary: Background: Genetic variants in COL4A1 and COL4A2 (encoding collagen IV alpha chain 1/2) occur in genetic and sporadic forms of cerebral small vessel disease (CSVD), a leading cause of stroke, dementia and intracerebral haemorrhage (ICH). However, the molecular mechanisms of CSVD with ICH and COL4A1/COL4A2 variants remain obscure. Methods: Vascular function and molecular investigations in mice with a Col4a1 missense mutation and heterozygous Col4a2 knock-out mice were combined with analysis of human brain endothelial cells harboring COL4A1/COL4A2 mutations, and brain tissue of patients with sporadic CSVD with ICH. Findings: Col4a1 missense mutations cause early-onset CSVD independent of hypertension, with enhanced vasodilation of small arteries due to endothelial dysfunction, vascular wall thickening and reduced stiffness. Mechanistically, the early-onset dysregulated endothelium-dependent hyperpolarization (EDH) is due to reduced collagen IV levels with elevated activity and levels of endothelial Ca2+-sensitive K+ channels. This results in vasodilation via the Na/K pump in vascular smooth muscle cells. Our data support this endothelial dysfunction preceding development of CSVD-associated ICH is due to increased cytoplasmic Ca2+ levels in endothelial cells. Moreover, cerebral blood vessels of patients with sporadic CSVD show genotype-dependent mechanisms with wall thickening and lower collagen IV levels in those harboring common non-coding COL4A1/COL4A2 risk alleles. Interpretation: COL4A1/COL4A2 variants act in genetic and sporadic CSVD with ICH via dysregulated EDH, and altered vascular wall thickness and biomechanics due to lower collagen IV levels and/or mutant collagen IV secretion. These data highlight EDH and collagen IV levels as potential treatment targets. Funding: MRC, Wellcome Trust, BHF.

Dagmawi Anteneh Teferi,1 Ayto Addisu Negash,2 Daniel Aman,2 Sisay Hailu,2 Taye Nigatu Tola,1 Yared G/Michael Tarekegn,3 Wubhareg Anteneh Teferi4 1Department of Surgery, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia; 2Department of Emergency Medicine and Critical Care, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia; 3Department of Internal Medicine, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia; 4School of Medicine and Health Science, Wolkite University, Wolkite, EthiopiaCorrespondence: Dagmawi Anteneh Teferi, Department of Surgery, St. Paul’s Hospital Millennium Medical College, Po.Box: 1271, Addis Ababa, Ethiopia, Email dagmawianteneh16@gmail.comBackground: Thyroid gland abscess is a rare pathology with life-threatening complications when there is a delay in diagnosis. However, physicians should be aware of and consider this differential in patients with anterior neck swelling having acute onset compressive symptoms to ensure early diagnosis and management.Case Presentation: A 62-year-old female patient presenting with worsening of painful anterior neck swelling with associated fever, shortness of breath, and difficulty swallowing. The patient was found to have a thyroid abscess causing upper airway obstruction, against a background of follicular nodular disease found on clinical examination, cytology and fluid analysis from aspirate, biopsy, ultrasonography, and computed tomography. The patient was managed with endotracheal intubation and was subsequently discharged after recovery with antibiotic therapy, incision and drainage, and thyroid lobectomy.Conclusion: Thyroid abscess is an uncommon, critical clinical condition with high morbidity and mortality. Thyroid gland abscess should be considered while evaluating patients presenting with acute onset anterior neck swelling. Satisfactory clinical outcomes could be achieved with early diagnosis and proper management.Keywords: thyroid abscess, thyroid emergency, upper airway obstruction, anterior neck mass, incision and drainage, thyroidectomy

Abstract Background Iron and folic acid (IFA) supplements are currently provided to Cambodian women during pregnancy. However, recent research has found benefits of a multiple micronutrient supplement (MMS) over just IFA alone on several outcomes of perinatal and infant health. The Ministry of Health in Cambodia has proposed a transition from IFA to MMS but to effectively guide this transition requires implementation research on the acceptability and adherence to MMS (over IFA). Methods This non-inferiority trial aims to assess the adherence and acceptability of IFA (60 mg elemental iron and 400 μg folic acid) compared to MMS (standard UNIMMAP formulation including 15 micronutrients) during antenatal care in Cambodia. A prospective cohort of 1545 pregnant women will be assigned to one of three trial arms: (1) IFA for 90 days [IFA-90]; (2) MMS for 180 days with two distributions of 90-count tablet bottles [MMS-90]; or (3) MMS for 180 days with one 180-count tablet bottle [MMS-180]. Each arm will enroll 515 women across 48 health centers (clusters) in Kampong Thom Province in Cambodia. The primary outcome is the non-inferiority of adherence rates of MMS-180 compared to IFA-90, as assessed by tablet counts. Mixed-effects logistic and linear regression models will be used to estimate the difference in the adherence rate between the two groups, with an ‘a priori’ determined non-inferiority margin of 15%. Acceptability of MMS and IFA will be measured using a quantitative survey conducted with enrolled pregnant women at 30-day, 90-day, and 180-day time-points. Discussion Findings from this study will guide an effective and feasible MMS scale-up strategy for Cambodia. Additionally, the findings will be shared globally with other stakeholders planning to scale up MMS in other countries. Trial registration NCT05867836 ( ClinicalTrials.gov , registered May 18, 2023).

Key Clinical Message This case demonstrated the rare “shark fin” ECG pattern, an ST‐segment elevation typically seen in acute myocardial infarction. We reported a case of takotsubo cardiomyopathy secondary to influenza A infection with multiple organ failure, showing the shark fin sign and resulting in in‐patient mortality and various complication.

Introduction The burden of multimorbidity is recognised increasingly in low- and middle-income countries (LMICs), creating a strong emphasis on the need for effective evidence-based interventions. Core outcome sets (COS) appropriate for the study of multimorbidity in LMICs do not presently exist. These are required to standardise reporting and contribute to a consistent and cohesive evidence-base to inform policy and practice. We describe the development of two COS for intervention trials aimed at preventing and treating multimorbidity in adults in LMICs.Methods To generate a comprehensive list of relevant prevention and treatment outcomes, we conducted a systematic review and qualitative interviews with people with multimorbidity and their caregivers living in LMICs. We then used a modified two-round Delphi process to identify outcomes most important to four stakeholder groups (people with multimorbidity/caregivers, multimorbidity researchers, healthcare professionals and policymakers) with representation from 33 countries. Consensus meetings were used to reach agreement on the two final COS. Registration: https://www.comet-initiative.org/Studies/Details/1580.Results The systematic review and qualitative interviews identified 24 outcomes for prevention and 49 for treatment of multimorbidity. An additional 12 prevention and 6 treatment outcomes were added from Delphi round 1. Delphi round 2 surveys were completed by 95 of 132 round 1 participants (72.0%) for prevention and 95 of 133 (71.4%) participants for treatment outcomes. Consensus meetings agreed four outcomes for the prevention COS: (1) adverse events, (2) development of new comorbidity, (3) health risk behaviour and (4) quality of life; and four for the treatment COS: (1) adherence to treatment, (2) adverse events, (3) out-of-pocket expenditure and (4) quality of life.Conclusion Following established guidelines, we developed two COS for trials of interventions for multimorbidity prevention and treatment, specific to adults in LMIC contexts. We recommend their inclusion in future trials to meaningfully advance the field of multimorbidity research in LMICs.PROSPERO registration number CRD42020197293.

Background: Sodium glucose cotransporter 2 inhibitors are recommended for the treatment of heart failure due to their cardioprotective effects, despite primarily being used as antidiabetic medications. However, the comparative profile of two antidiabetic drugs, sodium glucose cotransporter 2 inhibitors with dipeptidyl peptidase 4 inhibitor remains unclear. Study hypothesis: This study aims to compare the safety and efficacy profiles of sodium glucose cotransporter 2 inhibitors versus dipeptidyl peptidase 4 inhibitor drugs. Methods: A comprehensive search was conducted in PubMed, Scopus, Web of Science, Google Scholar, and ClinicalTrials.gov using appropriate Medical Subject Headings terms from inception until February 23, 2023. The outcomes were pooled using a random-effects model for hazard ratio with a 95% confidence interval. A p -value of

Key Clinical Message Sarcoidosis‐induced LETM represents a rare but life‐threatening neurological manifestation of sarcoidosis, characterized by spinal cord inflammation, and associated neurological deficits. Sarcoidosis should be included in the differential diagnosis of LETM, particularly in patients with no lung involvement. Prompt recognition and management are obligatory to optimize outcomes and prevent long‐term disability. Abstract Sarcoidosis is a multisystem inflammatory granulomatous disorder characterized by the formation of noncaseating granulomas. Although sarcoidosis commonly affects the skin, lymph nodes, and lungs, neurological involvement of sarcoidosis has also been reported. Longitudinally extensive transverse myelitis (LETM) is a rare but well‐documented serious manifestation of neuroscoidosis. We report a case of LETM caused by sarcoidosis in a 53‐year‐old male who presented with progressive bilateral lower extremity weakness, urinary retention, and paresthesia. Laboratory evaluations revealed elevated inflammatory markers. Magnetic resonance imaging of the spine showed hyperintense signals consistent with transverse myelitis. Cerebrospinal fluid analysis revealed lymphocytic pleocytosis and elevated protein levels. Chest computed tomography showed hilar lymphadenopathy. A biopsy of the intrathoracic lymph node showed noncaseating granulomas consistent with sarcoidosis. A diagnosis of sarcoidosis‐induced LETM was made after ruling out all other possible etiologies. His condition improved gradually after starting high‐dose prednisone, mycophenolate, and rehabilitation strategies. Our case underscores the importance of prompt diagnosis and management of sarcoidosis‐induced LETM and highlights that sarcoidosis must be included among differential diagnoses of LETM, especially in cases with no lung involvement.

Key Clinical Message This case highlights the importance of a definite diagnosis of an IgG4‐related chronic sclerosing duodenitis based on histological and radiological findings to rule out any malignancy in the mass. While dealing with patients having concentric duodenal thickening resulting in stricture formation, one should think of inflammatory etiology as well. IgG4‐related disease is one of these inflammatory disorders where we see soft tissue thickening without a large mass or any associated lymphadenopathy as in our case. Abstract Immunoglobulin G4‐related disease (IgG4‐RD) is distinguished as an infiltration of IgG‐4‐positive plasmacytes involving inflammatory lesions across multiple organs which is accompanied by raised IgG4 levels in the serum. Several inflammatory disorders are recognized as part of the IgG4‐RD family based on shared histopathological features, which include Mikulicz's disease, chronic sclerosing sialadenitis, or Riedel's thyroiditis. Our case highlights a distinctive presentation of IgG4‐related diseases; a 58‐year‐old man presenting with duodenal stricture highly suspicious of a duodenal mass/ampullary mass later found to be due to IgG4‐related sclerosing duodenitis with negative malignancy on biopsy. We present the diagnostic challenges faced and relevant findings noted.

Objective: To compare introducer needle technique versus cannula over the needle technique for guide-wire placement to perform successful central venous cannulation in neonates using ultrasonography Study Design: Quasi-experimental study. Place and Duration of Study: Department of Anaesthesia, Pak Emirates Military Hospital Rawalpindi Pakistan, from Feb 2020 to Jun 2021. Methodology: A total of 78 neonates who required central venous cannulation under general anaesthesia were randomly divided into two equal groups, Introducer Needle Group, Group-I (n=39), and Cannula Over the Needle Group, Group-II (n=39). Primary outcome measure was success on first attempt and secondary outcomes were total number of attempts until success and duration of procedure. Procedure related complications were also recorded. Results: Success on first attempt was much higher in Cannula over the Needle (CN) Group. Total number of attempts until successful cannulation were less in cannula over the needle (CN) group and time taken to perform successful cannulation was less in Cannula Over the Needle Group as compared to introducer needle group. Conclusion: In neonates if cannula over the needle is used instead of introducer needle, success on first attempt is more likely. Moreover, number of attempts are reduced and less time is taken to perform successful procedure.

IntroductionCardiovascular disease (CVD) stands as a pervasive catalyst for illness and mortality on a global scale, underscoring the imperative for sophisticated prediction methodologies within the ambit of healthcare data analysis. The vast volume of medical data available necessitates effective data mining techniques to extract valuable insights for decision-making and prediction. While machine learning algorithms are commonly employed for CVD diagnosis and prediction, the high dimensionality of datasets poses a performance challenge.MethodsThis research paper presents a novel hybrid model for predicting CVD, focusing on an optimal feature set. The proposed model encompasses four main stages namely: preprocessing, feature extraction, feature selection (FS), and classification. Initially, data preprocessing eliminates missing and duplicate values. Subsequently, feature extraction is performed to address dimensionality issues, utilizing measures such as central tendency, qualitative variation, degree of dispersion, and symmetrical uncertainty. FS is optimized using the self-improved Aquila optimization approach. Finally, a hybridized model combining long short-term memory and a quantum neural network is trained using the selected features. An algorithm is devised to optimize the LSTM model’s weights. Performance evaluation of the proposed approach is conducted against existing models using specific performance measures.ResultsFar dataset-1, accuracy-96.69%, sensitivity-96.62%, specifity-96.77%, precision-96.03%, recall-97.86%, F1-score-96.84%, MCC-96.37%, NPV-96.25%, FPR-3.2%, FNR-3.37% and for dataset-2, accuracy-95.54%, sensitivity-95.86%, specifity-94.51%, precision-96.03%, F1-score-96.94%, MCC-93.03%, NPV-94.66%, FPR-5.4%, FNR-4.1%. The findings of this study contribute to improved CVD prediction by utilizing an efficient hybrid model with an optimized feature set.DiscussionWe have proven that our method accurately predicts cardiovascular disease (CVD) with unmatched precision by conducting extensive experiments and validating our methodology on a large dataset of patient demographics and clinical factors. QNN and LSTM frameworks with Aquila feature tuning increase forecast accuracy and reveal cardiovascular risk-related physiological pathways. Our research shows how advanced computational tools may alter sickness prediction and management, contributing to the emerging field of machine learning in healthcare. Our research used a revolutionary methodology and produced significant advances in cardiovascular disease prediction.

Abstract Background Various service provision models for youth at risk of homelessness have been researched and implemented, including access to housing and physical and mental health resources. However, even with these interventions, we remain unaware of how best to manage symptoms of depression and anxiety and the rate of drug use in these populations primarily because of a lack of feasibility data. Methods This paper presents the results of a mixed-methods study in London, Canada, that examined the feasibility of implementing a biopsychosocial intervention, SKY Schools, in at-risk youth aged between 16 and 25 (n = 49). The study also recorded qualitative responses about the program’s usefulness from the perspective of the service users. The SKY Schools intervention consisted of social-emotional learning combined with Sudarshan Kriya Yoga, a standardized yoga-based breathing exercise routine. The intervention program was divided into two phases: an active learning phase and a reinforcement phase. The following feasibility outcome measures were collected: (1) the number of potential participants approached per month, (2) number (proportion) who were successfully screened, (3) the proportion of screened participants who enrolled, (4) the rate of retention in the study, (5) rate of adherence to study protocol, (6) proportion of planned ratings that were completed, (7) intervention cost per case, (8) completeness of final data for analysis, (9) length of time to collect all data, (10) quality of all collected data, (11) determining if partnering community organizations were willing to conduct the study as per study protocol, (12) determining if there were any capacity issues with partners providing intervention and investigators being able to perform the tasks that they were committed to doing, (13) determining if there were any problems of entering the data into a computer, (14) preliminary data about the safety of the intervention, and (15) preliminary estimate of treatment effects. Results All feasibility outcome measures were collectible. In the city of London, Canada it was feasible to conduct a pilot study in this population of youth at risk of homelessness. Foremost among the findings was a high retention rate (61.2%) and overall positive qualitative feedback with a number of potential suggestions to improve the delivery and quality of the intervention. However, we had a significantly low recruitment rate (0.27 participants per week) suggesting that multiple sites will be needed to achieve an adequate sample size for a subsequent definitive trial. Conclusions Future researchers may consider the findings of this feasibility study when designing a randomized control trial to further assess the efficacy and tolerability of SKY Schools. Trial registration Trial registration: Clinicaltrials.gov, identifier NCT02749240. Registered April 22, 2016, https://clinicaltrials.gov/ct2/show/NCT02749240 .

Ammar Mahmoud,1 Mansoor M Aman,2 Jennifer L Trumbo,3 Umera Paracha,4 Ashley Langell,5 Erika Petersen6 1Department of Pain Medicine, Northern Light Eastern Maine Medical Center, Bangor, ME, USA; 2Department of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA; 3Clinical Research Center, Northern Light Eastern Maine Medical Center, Bangor, ME, USA; 4Department of Neurology, Northern Light Eastern Maine Medical Center, Bangor, ME, USA; 5Department of Pain Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA; 6Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USACorrespondence: Ammar Mahmoud, Interventional Pain Management Clinic, Northern Light Eastern Maine Medical Center, 925 Union Street, Suite &num;2, Bangor, ME, USA, Tel +1 207-973-5918, Fax +1 207-973-8300, Email amahmoud@northernlight.orgObjective: Targeted drug delivery (TDD) via intrathecal drug delivery systems (IDDS) exposure and clinical adoption remains low despite multiple well-designed trials that demonstrate safety, efficacy, reliability, and cost-saving benefits. This study aims to understand the possible contributing factors starting with Pain Medicine fellowship training.Materials and Methods: An internet-based, anonymous pilot survey was distributed to pain medicine fellows enrolled in an Accreditation Council for Graduate Medical Education (ACGME) accredited pain medicine training program during the 2021– 2022 academic year. Fellowship programs were identified using published online ACGME accreditation data. The survey was distributed via email to fellowship program directors and coordinators and was made available through pain medicine societies.Results: Seventy-one of four hundred and twenty-three pain medicine fellows (17% response rate) completed the survey. Nine percent of respondents evidence-informed opinion coincided with the most recent Polyanalgesic Consensus Conference (PACC) guidelines recommendations for IDDS treatment indications. Fifty-one percent of respondents felt there was an unmet need for IDDS training. About one-third of respondents felt that lack of curriculum, faculty, and cases were barriers to IDDS use, respectively. Thirty-one percent of fellows reported sufficient training for IDDS in their fellowship programs. The majority (70%) of respondents somewhat or strongly support direct training by IDDS manufacturers.Conclusion: A wide variability exists surrounding IDDS training during ACGME accredited pain medicine fellowship. Insufficient case exposure and lack of a standardized curriculum may play a role in future therapy adoption. The results from this study call for a more standardized training approach with an emphasis on adequate clinical exposure, utilization of peer reviewed educational curriculum and supplemental material to aid pain medicine fellows’ education.Keywords: intrathecal drug delivery system, targeted drug delivery, Accreditation Council for Graduate Medical Education, neuromodulation

Fibroids or leiomyoma of myometrium are the most common benign tumor in females. There are currently many modalities, both medical and surgical, for the management of fibroid in today’s practice such that it is often confusing as to which treatment to apply to which patient. Fibroid patients often present with a variety of symptoms and demographic aspect. Therefore a single guideline is not sufficient to encompass the case management for a specific Fibroid patient. Similarly the incidence of uterine sarcoma in patients undergoing fibroid treatment is thought to be minimal, but there is a current debate whether this risk is underestimated. The novel approach towards fibroids has allowed greater extent of uterine preservation but at the cost of decreased direct histological access, hence resulting in delay of diagnosis, especially in the case where uterine sarcoma is a possibility. Therefore gynecologists have to face the clinical dilemma to diagnose accurately and choose the most suitable treatment from the vast array of options available for each patient. The purpose of this article is to reconsider the different methods of treatments available and apply the most tailored treatment in each patient. This is a platform to better counsel for fibroid patients and their management. Key Words: Fibroid uterus, case management, Ulipristal, Aromatase inhibitors, Invasive procedures.

Background: Breast cancer is the most common cancer among women worldwide and is the second most common in Nepal. This study assessed the effect of an educational intervention package on knowledge, perception, and behavioral intention for breast cancer screening among adolescent students of Kathmandu Metropolitan City. Methods: A pretest -posttest control group study design was used. Each intervention and control groups included 159 participants, selected from two randomly chosen public secondary schools. Both groups completed self-administered pretest-posttest questionnaires. Educational intervention was given to the intervention group. Data was entered in EpiData 3.1 and analysed by using IBM SPSS 16 version. Wilcoxon Signed Rank test compared the difference in pretest-posttest scores within groups, and the Mann-Whitney U tested the difference between the control and the intervention groups. Results: In pretest-posttest comparisons, the intervention group showed an increase in the percentage of participants scoring at least the median value across knowledge (change: 18.0%, p

Background: Inadequate breastfeeding can lead to significant morbidity, mortality, and long-term adverse health outcomes. Key messages promoting optimal breastfeeding are integral to Essential Nutritional Action, aimed at improving children’s nutritional status, especially those under the age of two. However, there is a dearth of data regarding the extent to which lactating mothers adhere to these key messages and the associated factors. Therefore, this study aimed to assess the level of practice of key messages for optimal breastfeeding and identify associated factors among lactating mothers living in the Boset District, Oromia, Ethiopia. Methods: A community-based cross-sectional study was conducted among 418 lactating mothers from January 1st to February 28th, 2022. The participants were selected using a systematic random sampling technique, and data were collected through interviewer-administered questionnaires. The collected data were entered into Epi Info version 7 and exported to SPSS version 25 for analysis. Binary logistic regressions were performed to examine the association between independent and dependent variables. Adjusted Odds Ratios with a 95% confidence interval were used to estimate the strength of the associations and statistical significance was declared at a p -value

Abstract SARS‐CoV‐2 acute respiratory distress syndrome (ARDS) induces uncontrolled lung inflammation and coagulopathy with high mortality. Anti‐viral drugs and monoclonal antibodies reduce early COVID‐19 severity, but treatments for late‐stage immuno‐thrombotic syndromes and long COVID are limited. Serine protease inhibitors (SERPINS) regulate activated proteases. The myxoma virus‐derived Serp‐1 protein is a secreted immunomodulatory serpin that targets activated thrombotic, thrombolytic, and complement proteases as a self‐defense strategy to combat clearance. Serp‐1 is effective in multiple animal models of inflammatory lung disease and vasculitis. Here, we describe systemic treatment with purified PEGylated Serp‐1 as a therapy for immuno‐coagulopathic complications during ARDS. Treatment with PEGSerp‐1 in two mouse‐adapted SARS‐CoV‐2 models in C57Bl/6 and BALB/c mice reduced lung and heart inflammation, with improved outcomes. PEGSerp‐1 significantly reduced M1 macrophages in the lung and heart by modifying urokinase‐type plasminogen activator receptor (uPAR), thrombotic proteases, and complement membrane attack complex (MAC). Sequential changes in gene expression for uPAR and serpins (complement and plasminogen inhibitors) were observed. PEGSerp‐1 is a highly effective immune‐modulator with therapeutic potential for severe viral ARDS, immuno‐coagulopathic responses, and Long COVID.

The management of unruptured brain arteriovenous malformations (ubAVMs) is a complex challenge to neurovascular practitioners. This meta-analysis aimed to identify the optimal management of ubAVMs comparing conservative management, embolization, radiosurgery, microsurgical resection, and multimodality. The search strategy was developed a priori according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the Ovid Medline, Embase, Web of Science, and Cochrane Library databases to identify relevant papers. Using R version 4.1.1., a frequentist network meta-analysis was conducted to compare different management modalities for the ubAVMs. Overall, the conservative group had the lowest risk of rupture (P-score=0.77), and the lowest rate of complications was found in the conservative group (P-score=1). Among different interventions, the multimodality group had the highest rupture risk (P-score=0.34), the lowest overall complications (P-score=0.75), the best functional improvement (P-score=0.65), and the lowest overall mortality (P-score=0.8). However, multimodality treatment showed a significantly higher risk of rupture (odds ratio [OR]=2.13; 95% confidence interval [95% CI]=1.18–3.86) and overall complication rate (OR=5.56; 95% CI=3.37–9.15) compared to conservative management; nevertheless, there were no significant differences in overall mortality or functional independence when considered independently. Conservative management is associated with the lowest rupture risk and complication rate overall. A multimodal approach is the best option when considering mortality rates and functional improvement in the context of existing morbidity/symptoms. Microsurgery, embolization, and radiosurgery alone are similar to the natural history in terms of functional improvement and mortality, but have higher complication rates.

Background: Vitamin D deficiency in inflammatory bowel disease (IBD) patients may have important clinical implications. Therefore, it is important to investigate the prevalence of vitamin D deficiency in patients with IBD to better understand its impact on disease management and outcomes. Objectives: To assess the prevalence of vitamin D deficiency in patients with IBD using a radioimmunoassay method. Material & Methods: This was a prospective, observational study conducted at the Department of Medicine, Government of Medical College Jammu, India for a year from 1 November 2021 to 31 October 2022. Adult patients from OPD and IPD with biopsy proven IBD were included. Results: A total of 40 patients were included in the study with mean age of 38.7 years. Majority of patients (70%) were male and 50% patients belonged to age group of 30-60 years. The mean vitamin D level was 25.6 ng/mL and 62.5% of patients observed with vitamin D deficiency. Both genders and age were affected, with a significant proportion of patients having abnormal vitamin D levels. The vitamin D level was found to be comparable between both genders (P>0.05) and age groups (0.229). Conclusion: The present study investigated the high prevalence of vitamin D deficiency among patients with IBD. Additionally, patients were supplemented with vitamin D and were followed for further monitoring and evaluation for their outcomes.

Diagnostics are widely considered crucial in the fight against antimicrobial resistance (AMR), which is expected to kill 10 million people annually by 2030. Nevertheless, there remains a substantial gap between the need for AMR diagnostics versus their development and implementation. To help address this problem, target product profiles (TPP) have been developed to focus developers’ attention on the key aspects of AMR diagnostic tests. However, during discussion between a multisectoral working group of 51 international experts from industry, academia and healthcare, it was noted that specific AMR-related TPPs could be extended by incorporating the interdependencies between the key characteristics associated with the development of such TPPs. Subsequently, the working group identified 46 characteristics associated with six main categories (ie, Intended Use, Diagnostic Question, Test Description, Assay Protocol, Performance and Commercial). The interdependencies of these characteristics were then identified and mapped against each other to generate new insights for use by stakeholders. Specifically, it may not be possible for diagnostics developers to achieve all of the recommendations in every category of a TPP and this publication indicates how prioritising specific TPP characteristics during diagnostics development may influence (or not) a range of other TPP characteristics associated with the diagnostic. The use of such guidance, in conjunction with specific TPPs, could lead to more efficient AMR diagnostics development.

Mastewal Zeleke,1 Almaz Badanie,2 Elsah Tegene Asefa,3 Wondu Reta Demissie,2 Getahun Chala,1 Husen Aman,4 Teka Obsa Feyisa,5 Mezgebu Legesse Habte5 1Department of Medical Physiology, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia; 2Department of Biomedical Sciences, College of Medicine and Health Sciences, Jimma University, Jimma, Ethiopia; 3Department of Medicine, College of Medicine and Health Sciences, Jimma University, Jimma, Ethiopia; 4Department of Human Anatomy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia; 5Department of Medical Biochemistry, College of Health and Medical Sciences, Haramaya University, Harar, EthiopiaCorrespondence: Mastewal Zeleke, Department of Medical Physiology, College of Health and Medical Sciences, Haramaya University, P.O.Box:235, Harar, Harari Regional State, Ethiopia, Tel +251911142917, Email mastewalzeleke2015@gmail.comBackground: Thyroid dysfunction (TD) is a metabolic manifestation related to either excessive or inadequate production of thyroid hormones. It has been widely proven to have comorbidities like cardiovascular disease. An electrocardiograph is a simple investigative instrument used to assess cardiac status to prevent complications in the later stages of the disease.Objective: To assess electrocardiogram (ECG) changes and associated factors among TD patients.Methods: An institution-based cross-sectional study was conducted among 273 TD patients attending Jimma Medical Center from October 11 to December 11, 2021. An ECG tool with 12 leads was used to assess the cardiac status, and a semi-structured questionnaire was used to assess sociodemographic, behavioral, and comorbidity variables. Bodyweight, height, waist circumference (WC), hip circumference (HC), and blood pressure variables were recorded, and body mass index (BMI) and waist-to-hip ratio (WHR) were calculated.Results: Out of a total of 273 analyzed and interpreted ECG results by the cardiologists, 185 (67.8%) had ECG alterations. The most common types of ECG changes were arrhythmia 153 (56%), followed by myocardial infarction 74 (27.1%), ventricular hypertrophy [left 20 (7.3%) and right 15 (5.5%)], left atrial enlargement 3 (1%), axis deviation, and other abnormalities 24 (8.8%) and 18 (6.6%), respectively. The identified predictor variables for the ECG changes were the age group of 41 to 60 years old [AOR = 2.5, 95% CI: 1.25, 5.05], being female [AOR = 2.7, 95% CI: 1.28, 5.59], having diabetes mellitus [AOR = 4.25, 95% CI: 1.6, 11.2], and not starting the treatment [AOR = 8.6, 95% CI: 3.45, 21.6].Conclusion: This study revealed that the prevalence of ECG changes was high among TD patients. The most common type of ECG change observed was arrhythmia followed by myocardial infarction. The age range of 41– 60 years old, being female, having diabetes mellitus, and not starting the treatment were significantly associated with the ECG changes. Implementing an efficient noninvasive screening of cardiac status can detect unrecognized and asymptomatic cardiac impairment in TD patients.Keywords: cardiovascular disease, electrocardiogram, Ethiopia, thyroid dysfunction

Objectives: This review aimed to critically appraise the evidence for biomarkers in blood serum, gingival crevicular fluid (GCF), saliva, and urine in comparison with standard radiographic indices for skeletal maturation assessment. Materials and Methods: A thorough literature search in multiple databases was conducted for biomarkers in body fluids for skeletal maturation assessed with cervical vertebrae in lateral cephalograms or on hand-wrist radiographs. Different combinations including free text, MeSH terms, and Boolean operators were used. Two researchers used strict inclusion and exclusion criteria to screen title, abstract, and full text, and used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 instrument for risk of bias assessment of individual studies. Meta-analysis was performed on eligible studies using RevMan 5 software. Results: A total of 344 articles were screened, of which 33 met the inclusion criteria and quality assessment. The skeletal maturity indicators included insulin-like growth factors (IGF-1), alkaline phosphatase (ALP), bone-specific alkaline phosphatase (BALP), dehydroepiandrosterone sulfate (DHEAS), vitamin D binding protein (DBP), parathormone-related protein (PTHrP), osteocalcin, metalloproteins, and serotransferrin (TF) along with different metabolites. At puberty, a significant rise was seen in IGF-1, DBP, ALP, osteocalcin, TF, and BALP. However, the serum DHEAS and PTHrP increased from pre-pubertal to post-pubertal stages. Due to the data heterogeneity, a meta-analysis could be performed on seven studies in total on IGF-1 in serum and blood. Of these, five were included for data in males and six in females, and four studies on IGF-1 in serum and blood. A significant difference in IGF-1 levels was seen between stages of peak pubertal growth spurt (CS3 and CS4) and decelerating pubertal growth (CS5) compared with growth initiation stage (CS2). Conclusions: Pubertal growth spurts were correlated with peak serum IGF-1 and BALP in both sexes individually. Peak ALP levels in GCF were correlated with the pubertal spurt in a combined sample of males and females. Standard biofluid collection protocols and homogeneity in sampling and methodology are strongly recommended for future research.

BackgroundThe growing number of older and oldest-old patients often present in the emergency room (ER) with undiagnosed geriatric syndromes posing them at high risk for complications in acute care.ObjectiveTo develop and validate an ER screening tool (ICEBERG) to capture 9 geriatric domains of risk in older patients.Design, setting, and participantsFor construct validity we performed a chart-based study in 129 ER patients age 70 years and older admitted to acute geriatric care (pilot 1). For criterion validity we performed a prospective study in 288 ER patients age 70 years and older admitted to acute care (pilot 2).ExposureIn both validation steps, the exposure was ICEBERG test performance below and above the median score (10, range 0–30).Outcome measures and analysisIn pilot 1, we compared the exposure with results of nine tests of the Comprehensive Geriatric Assessment (CGA). In pilot 2, we compared the exposure assessed in the ER to following length of hospital stay (LOS), one-on-one nursing care needs, in-hospital mortality, 30-day re-admission rate, and discharge to a nursing home.Main resultsMean age was 82.9 years (SD 6.7; n = 129) in pilot 1, and 81.5 years (SD 7.0; n = 288) in pilot 2. In pilot 1, scoring ≥10 was associated with significantly worse performance in 8 of 9 of the individual CGA tests. In pilot 2, scoring ≥10 resulted in longer average LOS (median 7 days, IQR 4, 11 vs. 6 days, IQR 3, 8) and higher nursing care needs (median 1,838 min, IQR 901, 4,267 vs. median 1,393 min, IQR 743, 2,390). Scoring ≥10 also increased the odds of one-on-one nursing care 2.9-fold (OR 2.86, 95%CI 1.17–6.98), and the odds of discharge to a nursing home 3.7-fold (OR 3.70, 95%CI 1.74–7.85). Further, scoring ≥10 was associated with higher in-hospital mortality and re-hospitalization rates, however not reaching statistical significance. Average time to complete the ICEBERG tool was 4.3 min (SD 1.3).ConclusionOur validation studies support construct validity of the ICEBERG tool with the CGA, and criterion validity with several clinical indicators in acute care.

Abstract Background The non-metric dental crown traits (NDCT) can vary within and between the geo-populations. These play a critical role in the ethnicity determination and help in identification of an individual. A commonly used system for scoring these dental traits is “Arizona State University Dental Anthropology System” (ASUDAS). Aim and objectives Our study aims to evaluate the frequency trend of twenty NDCT traits in the India, National Capital Region population using ASUDAS, and check for any significant sexual dimorphism for each trait. Methods The maxillary and mandibular dental casts from 200 patients (100 males+100 females, age 18–30 years) reporting to the dental OPD of a Government dental college were evaluated. Twenty dental crown traits were scored as per ASUDAS protocol in each dental cast by three investigators independently. NDCTs were tabulated and the chi-square test was performed for calculation of the P value. Results The results showed that the trait cusp number (83%) and lingual cusp variation (79%) were the two most frequent NDCTs and Y groove pattern (13%) and premolar accessory cusp-4 (12.5%) were the two least frequent traits observed. Shoveling of the upper lateral incisor (P=0.007), tuberculum dentale (P=0.049), mesial ridge (lingual) (P=0.034), and hypocone absence (P=0.001) were found to show statistically significant sexual dimorphism (P < 0.05). Although grade-wise expression of shoveling in upper lateral had statistically significant sexual dimorphism and the frequency of higher expression grades was found more in females, overall dichotomy of expression was not significant. Similarly, although an expression of grade-wise tuberculum dentale, mesial ridge (lingual) and hypocone absence had statistically significant sexual dimorphism, an overall dichotomy of expression was not significant. Conclusion The current study shows certain NDCTs like cusp number and lingual cusp variation have a significant association with the NCR population. Sexual dimorphism was not significant; hence, future studies should be planned on a large sample with sex pooled data for each precise location and ethnicity in all the regions of India. This can be further correlated with different facial forms and dental occlusal patterns, for correlation with abnormalities in jaws and teeth.

Aspergillus fumigatus can cause an immunological hypersensitivity reaction known as allergic bronchopulmonary aspergillosis (ABPA), which often worsens asthma and cystic fibrosis patients’ conditions. In India, where tuberculosis (TB) is endemic, a significant proportion of allergic bronchopulmonary aspergillosis (ABPA) patients are misdiagnosed as pulmonary TB before reaching a diagnosis of ABPA due to long-lasting symptoms. We discuss an uncommon presentation of ABPA with type II respiratory failure in a 48-year-old asthmatic female. Given this, one can speculate on the importance of ABPA presenting with respiratory failure since these cases are rare and diagnosed quite late, which can also prove fatal.

Telila Mesfin,1 Yohannes Tekalegn,2 Mudesir Aman,3 Girma Geta,4 Adugna Ketema,4 Fekata Defere,1 Dejene Girma,1 Mesfin Tsegaye,1 Takele Mengistu,1 Kenbon Seyoum4 1Department of Medicine, Madda Walabu University Goba General Hospital, Goba, Oromia, Ethiopia; 2Department of Public Health, Madda Walabu University Goba General Hospital, Goba, Oromia, Ethiopia; 3Department of Surgery, Madda Walabu University Goba General Hospital, Goba, Oromia, Ethiopia; 4Department of Midwifery, Madda Walabu University Goba General Hospital, Goba, Oromia, EthiopiaCorrespondence: Kenbon Seyoum, Tel +251915821035, Email kbseyoum8@gmail.comIntroduction: Foreign body ingestion causes a serious health problems like bleeding, abscess formation, septicemia, perforation, and obstruction of the esophagus, stomach and the intestine. In adults, foreign body ingestion is more common in the elderly, individuals with mental illness or who have an intellectual disability, alcohol poisoning, prison inmates, and drug traffickers.Case Presentation: We present a 22 year old male patient who presented with abdominal distension and vomiting of ingested matter of two to three episodes per day of one month duration. He is a known schizophrenic patient for the past three years and has been on follow up at a nearby hospital. He swallowed metallic nails in an attempt to kill himself. On abdominal examination there was distension, and epigastric tenderness. His plain abdominal x-ray showed multiple radiopaque foreign body in the stomach. Similarly, abdominal ultrasound showed thickened gastric wall and multiple linear foreign bodies in the stomach. Then, with the impression of gastric outlet obstruction secondary to foreign body in the stomach, laparotomy plus gastrotomy plus foreign body removal and repair were done under general anesthesia. Dilated stomach, palpable mass on distal stomach and first part of duodenum, and adhesion between stomach, abdominal wall and liver was found intra operatively.Conclusion: Passage of curved metal through the throat is a rare case. Mentally ill individuals need close follow up and physiological consultation.Keywords: foreign body ingestion, metal, Schizophrenia

Serum biomarkers and lung ultrasound are important measures for prognostication and treatment allocation in patients with COVID-19. Currently, there is a paucity of studies investigating relationships between serum biomarkers and ultrasonographic biomarkers derived from lung ultrasound. This study aims to assess correlations between serum biomarkers and lung ultrasound findings. This study is a secondary analysis of four prospective observational studies in adult patients with COVID-19. Serum biomarkers included markers of epithelial injury, endothelial dysfunction and immune activation. The primary outcome was the correlation between biomarker concentrations and lung ultrasound score assessed with Pearson’s (r) or Spearman’s (rs) correlations. Forty-four patients (67 [41–88] years old, 25% female, 52% ICU patients) were included. GAS6 (rs = 0.39), CRP (rs = 0.42) and SP-D (rs = 0.36) were correlated with lung ultrasound scores. ANG-1 (rs = −0.39) was inversely correlated with lung ultrasound scores. No correlations were found between lung ultrasound score and several other serum biomarkers. In patients with COVID-19, several serum biomarkers of epithelial injury, endothelial dysfunction and immune activation correlated with lung ultrasound findings. The lack of correlations with certain biomarkers could offer opportunities for precise prognostication and targeted therapeutic interventions by integrating these unlinked biomarkers.

BackgroundDiscrimination of bacterial and viral etiologies of childhood community-acquired pneumonia (CAP) is often challenging. Unnecessary antibiotic administration exposes patients to undue risks and may engender antimicrobial resistance. This study aimed to develop a prediction model using epidemiological, clinical and laboratory data to differentiate between bacterial and viral CAP.MethodsData from 155 children with confirmed bacterial or mixed bacterial and viral infection (N = 124) and viral infection (N = 31) were derived from a comprehensive assessment of causative pathogens [Partnerships for Enhanced Engagement in Research-Pneumonia in Pediatrics (PEER-PePPeS)] conducted in Indonesia. Epidemiologic, clinical and biomarker profiles (hematology and inflammatory markers) were compared between groups. The area under the receiver operating characteristic curve (AUROC) for varying biomarker levels was used to characterize performance and determine cut-off values for discrimination of bacterial and mixed CAP versus viral CAP. Diagnostic predictors of bacterial and mixed CAP were assessed by multivariate logistic regression.ResultsDiarrhea was more frequently reported in bacterial and mixed CAP, while viral infections more frequently occurred during Indonesia’s rainy season. White blood cell counts (WBC), absolute neutrophil counts (ANC), neutrophil-lymphocyte ratio (NLR), C-reactive protein (CRP), and procalcitonin (PCT) were significantly higher in bacterial and mixed cases. After adjusting for covariates, the following were the most important predictors of bacterial or mixed CAP: rainy season (aOR 0.26; 95% CI 0.08–0.90; p = 0.033), CRP ≥5.70 mg/L (aOR 4.71; 95% CI 1.18–18.74; p = 0.028), and presence of fever (aOR 5.26; 95% CI 1.07–25.91; p = 0.041). The model assessed had a low R-squared (Nagelkerke R2 = 0.490) but good calibration (p = 0.610 for Hosmer Lemeshow test). The combination of CRP and fever had moderate predictive value with sensitivity and specificity of 62.28 and 65.52%, respectively.ConclusionCombining clinical and laboratory profiles is potentially valuable for discriminating bacterial and mixed from viral pediatric CAP and may guide antibiotic use. Further studies with a larger sample size should be performed to validate this model.

OBJECTIVES Assessment of difficulties and glitches regarding internet connectivity faced by undergraduates and teachers during online learning. METHODOLOGY This study was conducted using an online questionnaire. 186 undergraduate students and teachers were included from CMH, Lahore. The duration of this study was 3 months. . RESULTS There was found to be no statistical difference in reluctance to use online platforms (p=0.17), frequent loss of internet (p=0.181), difficulty in dealing with the loss of connection (p=0.181), disturbance in planned schedule due to loss of connection (p=0.213), lagging behind in schedule (p=0.630), inability to convey the message (p=0.093), lack of internet in remote areas (p=0.302), lack of training to deal with connection problems (p=0.766), poor connection due to technical problems in devices (p=0.089) and poor quality internet (p=0.740) among faculty and students. CONCLUSION The problems due to internet connectivity issues in online education were faced more by students as compared to faculty.

Abstract We describe a case of left foot and ankle complex regional pain syndrome type 1 that necessitated a novel combination of a functioning dorsal root ganglion stimulation and peripheral nerve stimulation. This approach optimized pain relief, functional improvement, and avoided amputation.

Abstract Background People living with HIV (PLHIV) have an increased risk of developing active tuberculosis (TB). To reduce the burden of TB among PLHIV, the World Health Organization (WHO) recommends systematic TB screening followed by (1) confirmatory TB testing for all who screen positive and (2) TB preventive therapy (TPT) for all TPT-eligible PLHIV who screen negative. Symptom-based screening remains the standard of care in most high TB burden settings, including Uganda. Despite having high sensitivity for active TB among antiretroviral-naïve PLHIV, symptom screening has poor specificity; as such, many high-risk PLHIV without active TB are not referred for TPT. C-reactive protein (CRP) is a promising alternative strategy for TB screening that has comparable sensitivity and higher specificity than symptom screening, and was endorsed by WHO in 2021. However, the impact of CRP-based TB screening on TB burden for PLHIV remains unclear. Methods TB SCRIPT (TB Screening Improves Preventive Therapy Uptake) is a phase 3, multi-center, single-blinded, individual (1:1) randomized controlled trial evaluating the effectiveness of CRP-based TB screening on clinical outcomes of PLHIV. The trial aims to compare the effectiveness of a TB screening strategy based on CRP levels using a point-of-care (POC) assay on 2-year TB incidence and all-cause mortality (composite primary trial endpoint) and prevalent TB case detection and uptake of TPT (intermediate outcomes), relative to symptom-based TB screening (current practice). Discussion This study will be critical to improving selection of eligible PLHIV for TPT and helping guide the scale-up and integration of TB screening and TPT activities. This work will enable the field to improve TB screening by removing barriers to TPT initiation among eligible PLHIV, and provide randomized evidence to inform and strengthen WHO guidelines. Trial registration ClinicalTrials.gov NCT04557176. Registered on September 21, 2020.

Antimicrobial resistance (AMR) constitutes a serious impediment to the attainment of the World Health Organization's Sustainable Development Goals, which seek to ensure and promote healthy living among humans and animals. Studies have identified the vulnerability of conflict-affected populations to exposure to antimicrobial-resistant pathogens. Resource-limited countries like Afghanistan have suffered for long periods from armed conflicts, and this situation is exacerbated by the already poor or dilapidated healthcare delivery services. The country has suffered human and economic losses due to antimicrobial-resistant bacterial infections driven by the prolonged war, as well as a limited number of antimicrobials and frequent under dosage. Most reports point to the overuse of broad-spectrum antibiotics as the main reason for building up resistant strains. There is a need for more efforts toward identifying the major contributors and enlightening the public on the importance of AMR. This review aimed to provide a critical appraisal regarding the current situation of AMR in Afghanistan.

Abstract Background The coronavirus disease 2019 (COVID-19) pandemic has led to a disruptive increase in the number of intensive care unit (ICU) admissions with acute respiratory distress syndrome (ARDS). ARDS is a severe, life-threatening medical condition characterized by widespread inflammation and vascular leak in the lungs. Although there is no proven therapy to reduce pulmonary vascular leak in ARDS, recent studies demonstrated that the tyrosine kinase inhibitor imatinib reinforces the endothelial barrier and prevents vascular leak in inflammatory conditions, while leaving the immune response intact. Methods This is a randomized, double-blind, parallel-group, placebo-controlled, multicenter clinical trial of intravenous (IV) imatinib mesylate in 90 mechanically ventilated subjects with COVID-19-induced ARDS. Subjects are 18 years or older, admitted to the ICU for mechanical ventilation, meeting the Berlin criteria for moderate-severe ARDS with a positive polymerase chain reaction test for SARS-CoV2. Participants will be randomized in a 1:1 ratio to either imatinib (as mesylate) 200 mg bis in die (b.i.d.) or placebo IV infusion for 7 days, or until ICU discharge or death. The primary study outcome is the change in Extravascular Lung Water Index (EVLWi) between day 1 and day 4. Secondary outcome parameters include changes in oxygenation and ventilation parameters, duration of invasive mechanical ventilation, number of ventilator-free days during the 28-day study period, length of ICU stay, and mortality during 28 days after randomization. Additional secondary parameters include safety, tolerability, and pharmacokinetics. Discussion The current study aims to investigate the efficacy and safety of IV imatinib in mechanically ventilated subjects with COVID-19-related ARDS. We hypothesize that imatinib decreases pulmonary edema, as measured by extravascular lung water using a PiCCO catheter. The reduction in pulmonary edema may reverse hypoxemic respiratory failure and hasten recovery. As pulmonary edema is an important contributor to ARDS, we further hypothesize that imatinib reduces disease severity, reflected by a reduction in 28-day mortality, duration of mechanical ventilation, and ICU length of stay. Trial status Protocol version and date: V3.1, 16 April 2021. Recruitment started on 09 March 2021. Estimated recruitment period of approximately 40 weeks. Trial registration ClinicalTrials.gov NCT04794088 . Registered on 11 March 2021.

Schatzkter type-I tibial plateau fracture is a split fracture of the lateral tibial plateau in sagittal plane, consequent to valgus impaction caused by low velocity of trauma. However, a deep understanding of the different columns of the tibial plateau and patho-mechanisms of the injury led to the unmasking of atypical fractures around the tibial plateau. We have encountered 2 cases with unusual fracture pattern of the lateral tibial condyle caused by road traffic accidents. The fracture pattern and severity of injury deviate from the original description of Schatzker type 1; in view of dual plane split, there is rotation of the posterolateral column fragment along its sagittal plane plus grade-III medial collateral ligament injury. The patients were initially treated with knee spanning external fixator and after a latency of 5 days, definitive fracture specific fixation was done, combined with repair of grade-III medial collateral ligament injury. At the 6 months follow-up both the patients achieved satisfactory knee functions (knee society score case 1: 100 and case 2: 92) and returned to their jobs. The severity of fracture pattern and displacement as described should prompt for examination of associated ligament injury. Because of timely diagnosis, early and appropriate care promised an excellent function outcome even in such a severe nature of knee injury. To prompt the description of injury pattern we coined the name “dual split and dislocation” of lateral tibial plateau, as a complex injury variant of split fracture of lateral tibial plateau fracture.

Objective: The need for telemedicine was felt more than ever during the COVID-19 pandemic, which impacted health care worldwide. Therefore, this study aimed to determine the difficulties faced by patients in visiting the cardiac outpatient department during COVID-19, along with assessing the awareness and acceptability of telemedicine. Methods: In this cross-sectional study, selected patients presenting to outpatient department of a tertiary care cardiac hospital were interviewed regarding the difficulties faced by patients in visiting the outpatient department during COVID-19 and their awareness and acceptability of telemedicine using a self-designed structured questionnaire. Results: Of the 403 patients, 58.3% were male, the mean age was 53.04 ± 11.73 years, and most (77.7%) were urban residents. Ischemic heart disease was present in 69.5%, followed by hypertension (38.7%) and heart failure (29.3%). A total of 26.6% required emergency room visits. Limited appointments (55.6%) was the most common problem faced by patients during COVID-19, followed by financial issues (17.1%), fear of acquiring infection (13.4%), and limited mobility due to lockdown (22.6%). Only 12.2% were aware of telemedicine, 4.5% had previously used it, and 41.2% were willing to opt for telemedicine in the future. No internet access (39.2%) was the key barrier to the usage of telemedicine, followed by a lack of free medicine (39%) and a lack of a smart device (31.5%). Conclusion: Limited appointments due to COVID-19 restrictions has made it difficult for patients to visit the clinics, which has led to increased emergency room visits. Telemedicine awareness was found to be limited; however, many patients were willing to adopt it provided their limitations could be overcome.

Cell migration is essential in numerous living processes, including embryonic development, wound healing, immune responses, and cancer metastasis. From individual cells to collectively migrating epithelial sheets, the locomotion of cells is tightly regulated by multiple structural, chemical, and biological factors. However, the high complexity of this process limits the understanding of the influence of each factor. Recent advances in materials science, tissue engineering, and microtechnology have expanded the toolbox and allowed the development of biomimetic in vitro assays to investigate the mechanisms of cell migration. Particularly, three-dimensional (3D) hydrogels have demonstrated a superior ability to mimic the extracellular environment. They are therefore well suited to studying cell migration in a physiologically relevant and more straightforward manner than in vivo approaches. A myriad of synthetic and naturally derived hydrogels with heterogeneous characteristics and functional properties have been reported. The extensive portfolio of available hydrogels with different mechanical and biological properties can trigger distinct biological responses in cells affecting their locomotion dynamics in 3D. Herein, we describe the most relevant hydrogels and their associated physico-chemical characteristics typically employed to study cell migration, including established cell migration assays and tracking methods. We aim to give the reader insight into existing literature and practical details necessary for performing cell migration studies in 3D environments.

Summary: Background: Catatonia is a psychomotor syndrome that has a wide range of aetiologies. Determining whether catatonia is due to a medical or psychiatric cause is important for directing treatment but is clinically challenging. We aimed to ascertain the performance of the electroencephalogram (EEG) in determining whether catatonia has a medical or psychiatric cause, conventionally defined. Methods: In this systematic review and meta-analysis of diagnostic test accuracy (PROSPERO CRD42021239027), Medline, EMBASE, PsycInfo, and AMED were searched from inception to May 11, 2022 for articles published in peer-reviewed journals that reported EEG findings in catatonia of a medical or psychiatric origin and were reported in English, French, or Italian. Eligible study types were clinical trials, cohort studies, case–control studies, cross-sectional studies, case series, and case reports. The reference standard was the final clinical diagnosis. Data extraction was conducted using individual patient-level data, where available, by two authors. We prespecified two types of studies to overcome the limitations anticipated in the data: larger studies (n ≥ 5), which were suitable for formal meta-analytic methods but generally lacked detailed information about participants, and smaller studies (n

OBJECTIVES To find the frequency radiolucencies associated with the second molar adjacent to an impacted third molar in the maxilla as compared to the mandible. METHODOLOGY A cross-sectional descriptive study was conducted on 385 Orthopantomograms (OPG) of patients visiting Sharif Medical and Dental College (SMDC), Services Institute of Medical Sciences (SIMS) and Institute of Dentistry, CMH, Lahore Medical College, Lahore over a period of three months from December 2020 to February 2021. Patients above the age of 21 years were included in this study. Grossly carious third molars with inadequate tooth structure to be evaluated and patients with missing maxillary and mandibular third molars were excluded from the study. RESULTS The association between periapical radiolucencies (p=0.140), pericoronal radiolucencies (p=1.000) and external root resorption (p= 0.157) with the arch type (mandible/ maxilla) were not statistically significant but that of caries with the arch was significant (p≤0.001). CONCLUSION The periapical and pericoronal radiolucencies, caries and external root resorption associated with the second molar in the presence of an impacted third molar were higher in the mandible as compared to the maxilla.

BackgroundAtopic dermatitis (AD) is a chronically relapsing disease. Few biologics are approved for moderate-to-severe AD, and novel interventions are emerging. We aimed to evaluate the safety and efficacy of lebrikizumab, an IL-13 immunomodulator, as monotherapy vs. placebo in treating moderate-to-severe AD.MethodsCochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, and ClinicalTrials.gov registry (CT.gov) databases were systematically searched. We evaluated lebrikizumab vs. placebo and measured efficacy using Eczema Area and Severity Index (EASI), Body Surface Area (BSA), and Investigator’s Global Assessment (IGA) change from baseline to week 16. Safety was evaluated by the incidence of serious adverse events (SAEs), non-serious adverse events (NSAEs), and mortality. The risk of bias was investigated using the Revised Cochrane risk of bias tool.ResultsThree RCTs (n = 1,149) included 543 (47.25%) men vs. 606 (52.75%) women. Meta-analysis showed statistically significant improvement in EASI, IGA, and BSA. EASI75 at week 16 for all regimens was (RR = 2.62, 95% CI [2.06, 3.34], p < 0.00001) with the first regimen (500 mg loading dose then 200 mg every 2 weeks) showing the most significant improvement (RR = 3.02, 95% CI [2.39, 3.82], p < 0.00001). The pooled analysis of safety outcomes concluded that lebrikizumab did not correlate significantly with the incidence of SAEs, NSAEs, and mortality.ConclusionOverall, lebrikizumab showed a significant improvement in all efficacy outcomes. Additionally, it did not contribute to any significant incidence of SAEs, NSAEs, or mortality. The risk of bias in included RCTs was minor except in the randomization domain. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment of the outcomes ranged from low to high, but predominantly high certainty of evidence.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, identifier CRD42022362438.