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Venous thromboembolism (VTE) comprises deep vein thrombosis (DVT) and pulmonary embolism (PE). Acute PE is associated with significant morbidity and mortality. Hospital admission is a common cause of VTE.We present a complex case of a young female patient who sustained a right tibial plateau fracture following a traumatic, hyperextension knee injury. The patient was admitted by the orthopaedic team for an open reduction and internal fixation and commenced on prophylactic low molecular weight heparin. Post-operatively, the patient became hypoxic, and computed tomography pulmonary angiogram confirmed bilateral large volume pulmonary emboli with evidence of right heart strain. Following review by the pulmonary embolism response team (PERT), the patient was stratified into an intermediate-high risk group, and received unfractionated heparin, however, remained tachycardic and hypoxic with rising lactate levels. Owing to relative contraindications to systemic thrombolysis, the patient underwent catheter-based thrombectomy and inferior vena cava filter placement. The patient improved dramatically over the course of her admission and was later discharged, asymptomatic from a cardiopulmonary standpoint. In hospitalised patients, early VTE risk assessment and prompt initiation of appropriate thromboprophylaxis are crucial in preventing hospital-acquired VTE (HAVTE). However, in instances of HAVTE in complex patients, a well-coordinated multidisciplinary PERT is necessary to consider alternative strategies for managing intermediate to high-risk PE.

Abstract Background Interstitial lung disease (ILD) remains one of the most important causes of morbidity and mortality in patients with Connective Tissue Diseases (CTD). This study evaluated the impact of hospitalization on mortality in an ethnically and racially diverse cohort of CTD-ILD patients. Methods We conducted a medical records review study at Montefiore Medical Center, Bronx, NY. We included 96 patients and collected data on demographic characteristics, reasons for hospitalization, length of stay, immunosuppressant therapy use, and mortality. We stratified our patients into two cohorts: hospitalized and non-hospitalized. The hospitalized cohort was further subdivided into cardiopulmonary and non-cardiopulmonary admissions. Two-sample tests or Wilcoxon’s rank sum tests for continuous variables and Chi-square or Fisher’s exact tests for categorical variables were used for analyses as deemed appropriate. Results We identified 213 patients with CTD-ILD. Out of them, 96 patients met the study’s inclusion criteria. The majority of patients were females (79%), and self-identified as Hispanic (54%) and Black (40%). The most common CTDs were rheumatoid arthritis (RA) (29%), inflammatory myositis (22%), and systemic sclerosis (15%). The majority (76%) of patients required at least one hospitalization. In the non-hospitalized group, no deaths were observed, however we noted significant increase of mortality risk in hospitalized group (p = 0.02). We also observed that prolonged hospital stay (> 7 days) as well as older age and male sex were associated with increased mortality. Conclusions Prolonged (> 7 days) hospital stay and hospitalization for cardiopulmonary causes, as well as older age and male sex were associated with an increased mortality risk in our cohort of CTD-ILD patients.

A 7 years old girl diagnosed as case of juvenile idiopathic arthritis since the age of 1.5 years, generalized onset with systemic presentation is complicated by secondary nephrotic syndrome. Renal biopsy showing amyloidosis. Patient has severe disease course being complicated by sever flare ups of disease symptoms and body swelling. Since onset of disease patient got NSAIDs, methotrexate, steroids, anti TNF inhibitors with no or partial response. After diagnosis with secondary nephrotic syndrome due to secondary amyloidosis patient is started on intravenous tocilizumab. There is improvement of patient symptoms.

BackgroundCerebral palsy (CP) is a prevalent nonprogressive disorder that leads to impaired movement (ie, spasticity), posture, and balance, which affects functions such as walking and upper extremity tasks. Current medical treatments show efficacy in improving motor performance but have considerable side effects. Emerging off-label use of central nervous system (CNS) medications for improving motor performance has shown promising results in children with CP and other populations. ObjectiveThe aim of this study is to describe a protocol for a pilot randomized controlled trial (RCT) to examine the safety, tolerability, and efficacy of methylphenidate (MPH) and modafinil on spasticity and motor performance in children with CP. MethodsThis will be a protocol study for a pilot, triple-masked, placebo-controlled RCT (a class I trial following the American Academy of Neurology criteria) with blinded patients, outcome assessors, and intervention delivery team. Eligible children should be diagnosed with CP levels I or II based on the Gross Motor Function Classification System and be aged between 7 and 12 years. Thirty-six children with CP will be randomized into 3 groups to receive (1) MPH (2.5 mg of MPH + 100 mg placebo), (2) modafinil (100 mg modafinil + 2.5 mg placebo), or (3) a placebo (2.5 mg placebo + 100 mg placebo), in addition to physical therapy for 12 weeks. Primary outcomes include the Gross Motor Function Measure–66 and the Modified Ashworth Scale. Secondary outcomes include the Timed Up and Go test, 5 Time Sit to Stand test, Modified Clinical Test for Sensory Interaction of Balance, and 10-Meter Walk Test. ResultsThe protocol has been accepted by Kuwait University (VDR/EC-225) and the Ministry of Health of Kuwait (2022/2157). The inclusion of participants will start in June 2024. ConclusionsThe combination of CNS stimulant medications and controlling for rehabilitation has not been studied yet. The findings of this study may determine if using CNS stimulant medications is beneficial for the reduction of spasticity and improvement of physical function in children with spastic CP. Trial RegistrationClinicalTrials.gov NCT05675098; https://clinicaltrials.gov/study/NCT05675098 International Registered Report Identifier (IRRID)PRR1-10.2196/53728

Pulmonary embolism is a common disease associated with significant morbidity and mortality. Existing validated risk stratification tools have enabled the rapid identification of patients with low versus high-risk pulmonary embolism. Intermediate-high risk pulmonary embolism is defined as pulmonary embolism with haemodynamic stability, evidence of right ventricular dysfunction and elevated cardiac biomarkers. The therapeutic management of intermediate-high risk pulmonary embolism in the acute setting is challenging as these patients are often unwell, but do not fulfil criteria for high-risk pulmonary embolism. Although current guidelines recommend prompt first-line treatment with systemic anticoagulation and monitoring for deterioration, alternative strategies are being increasingly considered in this cohort. These include systemic or catheter-directed thrombolysis, surgical embolectomy, and mechanical circulatory support. In this case series, we discuss three cases of intermediate-high risk pulmonary embolism with a focus on multidisciplinary decision making in clinical management. Following on from this, we provide a brief narrative review of the current literature and guidelines surrounding this topic, considering the risks and benefits of alternative therapy options on patient outcomes.

Numerous studies indicated that patients with tobacco use disorder (TUD) are inversely associated with mortality in what is known as the smoker's paradox. However, limited studies have been conducted on the impact of TUD on the in-hospital mortality rates of patients with secondary pulmonary hypertension (PH, Non-Group 1 PH). Using the 2019 National Inpatient Sample, we identified PH and divided it into TUD and non-TUD to compare the comorbidities and in-hospital mortality between the two after 1:1 propensity-score matching. Of 1,129,440 PH hospitalizations, 12.1 % had TUD. After matching (n=133545, each group), TUD had lower median age (62 vs. 63), higher females (49 vs. 46.6 %), blacks (25.9 vs. 25.3 %), lower household income (40.8 vs. 32.7 %), Medicaid (22.4 vs. 14.8 %), non-elective (93.5 vs. 89.8 %), rural (9.3 vs. 6.7 %), urban non-teaching (17.2 vs 15.8 %) admissions. All CV comorbidities and other substance use were higher in TUD except CHF and valvular heart disease, TUD+ cohort and lower mortality (3.3 vs. 4.2 %, OR 0.78, p

Background: There is mounting evidence to suggest that high adherence to the Mediterranean diet (MedDiet) may reduce the risk of age-related diseases, including Parkinson’s disease (PD). However, evidence for the role of the MedDiet in the relief of motor and non-motor symptoms in patients with PD remains limited and inconclusive. We provide a systematic review of the effects of the MedDiet on the clinical features of PD using data from randomised controlled trials (RCT) and prospective observational studies. Methods: We searched MEDLINE, EMCare, EMBASE, Scopus and PubMed from inception until June 2023. Reference lists and the grey literature were also searched. Human studies with no restriction on language or publication date, examining associations between MedDiet adherence and the symptoms of PD, were included. We employed standard methodological procedures for data extraction and evidence synthesis and used the Quality Criteria Checklist for assessing the studies included. Results: Four studies from three unique cohorts, including two observational studies (n = 1213) and one RCT (n = 70), met the inclusion criteria. Despite the short study duration reported in all included reports, high MedDiet adherence was associated with changes in the gut microbiota (e.g., increased abundance of short-chain fatty acids producers). These outcomes correlated with a significant improvement in several non-motor symptoms including cognitive dysfunction, dyspepsia and constipation. However, there were no significant changes in diarrhoea, gastrointestinal reflux, abdominal pain and motor symptoms. Conclusion: High MedDiet adherence may be associated with significant improvement in global cognition and several gastrointestinal symptoms, possibly associated to changes in gut microbiota composition. Further studies are warranted to clarify potential cause-and-effect relationships and to elucidate MedDiet impact on motor symptoms.

IntroductionInvestigating the epidemiology of mental health disorders resulting from COVID-19 intervention measures, primary school closures, and social isolation in children and adolescents needs to be prioritized over adults at the post-pandemic stage. Most preliminary psychosocial studies conducted during the pandemic have demonstrated that younger age groups are the most vulnerable to such implications. Thus, this study aims to estimate the probable prevalence of specific anxiety disorders in children and quantify their relationships with relevant demographic risk factors.MethodsWe used a cross-sectional study comprising 430 children aged between 8- and 18 years old living in Kuwait during the period of school closures as well as full and partial lockdowns. The survey included questions about participants’ characteristics, children's anxiety using the Screen for Child Anxiety Related Emotional Disorders Questionnaire (SCARED) scale, and children's emotions and behaviours using the Strengths and Difficulties Questionnaire (SDQ). Univariate and multivariate logistic regression analyses were used to summarize the demographic and characteristics of the participants and their association with general, social, and generalized anxieties, as well as behavioural and emotional difficulties. ResultsWe inferred that 24.83% of our participants had at least one anxiety disorder, while 20.19% were classified as abnormal on the SDQ scale. Our multivariate analysis revealed that lockdown duration and sex of the child were consistently significant predictors (p-values < 0.05) of the broad spectrum of selected mental disorders. Additionally, we inferred notable increases in the likelihood of mental disorders associated with the increased duration of lockdowns. ConclusionsOur findings revealed preliminary insights into the vulnerability of young populations to the indirect negative impacts of strict public health measures during pandemic emergencies. Thus, authorities should consider such implications when planning and implementing similar interventions in future pandemics.

Background The potential impact of exercise on valvular function and aortic diameters in patients with a bicuspid aortic valve remains unclear. Therefore, we assessed the association between lifelong exercise characteristics, valvular dysfunction, and aortic dilatation in patients with a bicuspid aortic valve. Methods and Results In this cross‐sectional study, exercise volume (metabolic equivalent of task minutes per week), exercise intensity, and sport type were determined from the age of 12 years to participation using a validated questionnaire. Echocardiography was used to assess aortic stenosis or aortic regurgitation and to measure diameters at the sinuses of Valsalva and ascending aorta. Aortic dilatation was defined as a Z‐score ≥2. Four hundred and seven patients (42±17 years, 60% men) were included, of which 133 were sedentary (

Background and Aim Violence among intimate partners is a major public health concern resulting in violation of human rights. Efficacy of a planned education program on knowledge regarding intimate partner violence was investigated in this study. The studyrsquos objective was to improve the fourth year B.Sc. nursing studentsrsquo understanding of intimate partner violence.Methods Two-group pre-test and post-test study design using a quasi-experimental approach was followed. Eighty fourth year BSc nursing students from select Mangaluru nursing colleges were included in the study using a convenient sampling technique. Statistical analysis was done using Chi-Square paired and unpaired ldquotrdquo tests Fisherrsquos exact test.Results The mean pretest and post-test scores of the experiment group were 14.55 plusmn 3.637 and 18.73 plusmn 4.089 respectively with a 28.69 improvement which was highly significant P 0.001. Overall difference in the knowledge between experimental and control groups was found to be significant P 0.007. No significant association was found between socio demographic factors and the pretest levels of knowledge in both the groups except for the source of information regarding intimate partner violence chi2 7.025 P 0.008 in experiment group.Conclusion The study concluded that in comparison to their prior knowledge fourth year BSc nursing students had a significantly higher understanding of intimate partner abuse after implementation of teaching programme. The intended teaching program can bring significant improvement among final year BSc Nursing students and suggested that further evidence-based research should be conducted to raise awareness knowledge regarding intimate partner violence.

Background and aim Obstetric triage facilitates timely management of emergency cases. Obstetric triage can be counted as the best approach to reduce the length of hospital stay for increasing patient satisfaction reducing unnecessary admissions decreasing maternal and foetal mortality thereby improving obstetric care services. The present study aimed to determine the effectiveness of an education intervention program on knowledge about obstetric triage.Methods In the present study a two-group pre-test post-test quasi experimental research design was adopted. Eighty final year BSc nursing students were selected using convenient sampling technique from few select nursing colleges in Mangaluru. The pretest was conducted using a validated knowledge questionnaire following which educational intervention was administered for students in the experimental group. Subsequently a post intervention test was conducted after eight days using the same tool for all the students. Data analysis was done using Chi-square Fisher exact paired and unpaired lsquotrsquo tests.Results The study results confirmed that the educational intervention program was successful in improving the knowledge of nursing students. In the experimental group the mean pretest and post test scores were 11.73plusmn3.493 and 20.75plusmn3.774 respectively. In the control group the mean pre and post test scores were 13.28plusmn3.530 and 13.23plusmn2.370 respectively. There was a statistically significant difference in the overall knowledge scores between experimental and control groups P 0.001. There was no significant relationship between the socio demographic factors and the pre-test scores of experimental and control groups.Conclusion The current study revealed that the educational intervention program was more effectual in increasing the knowledge among nursing students and recommends that obstetric triage can be considered to be included in the nursing curriculum.

Background and aim The process of investigating analysing diagnosing treating and recommending preventive measures for human health and disease has been revolutionized by genetics. A thorough understanding of genomics has paved the way for individualized methods of providing health care that makes use of a persons environment and genes to help treat diagnose or prevent disease. Being the backbone of the healthcare team nurses need to be prepared to keep up with advances in genomics and the resulting transformation of the healthcare industry. The aim of the present research was to assess the knowledge and readiness in genomic nursing practice.Methods Using a convenient sampling 148 third- and fourth-year BSc nursing students were recruited for this cross-sectional descriptive design study. A standardized knowledge questionnaire on genomic nursing and a readiness rating scale was used to gather data. Both descriptive and inferential statistics were applied to analyze the data.Results The results revealed that more than half of the respondents 99 67 had poor 45 30 had satisfactory and 4 3 had a good level of knowledge regarding genomic nursing. Majority of the respondents 78 115 reported non-readiness in practicing genomic nursing whereas only 22 33 were ready to practice genomic nursing. There was no significant correlation between baseline variables and knowledge scores regarding genomic nursing at 0.05 level of significance.Conclusion The results of the current study revealed that among 148 participants third and final year BSc nursing students majority of students lacked knowledge regarding genomic nursing. With regards to confidence in practicing genomic nursing majority were somewhat confident only a few students were very confident and some were not at all confident. The study recommends a greater focus on genomic concepts as inclusion of genomics in health care can revolutionize the treatment.

This review aims to evaluate the effectiveness of Creating Opportunities for Parent Empowerment COPE on stress anxiety coping and competence among the mothers of preterm neonates admitted in Neonatal Intensive Care Unit NICU. Over the last decade premature birth rates have been steadily rising and owing to the technological advances even survival of the extreme preterm babies is a possibility. As many preterm babies thrive and survive focus must also be given to the parents especially the mothers who deliver before their estimated time of delivery. It is believed that most of the mothers undergo emotional turmoil as they are mentally not prepared for it. At times mothers feel helpless and reduced maternal confidence may lead to poor outcomes in the preterm baby care. Helping mothers to deal with this phase is essential. Coping strategies and support received from such mothers differ from place to place. Studies have been conducted for improving the coping of mothers with preterm babies and COPE has been highlighted as a useful strategy for better maternal adaptation. The findings of this review may help explore the outcomes of COPE program in alleviating the maternal emotional distress. This review will utilize studies that have used COPE program and its effect on mothers with preterm in the NICU on the stress anxiety coping and competence. The studies can be truequasi-experimental in nature. Research papers that evaluate any of the components of stress anxiety coping and competence will be considered. Both published and unpublished papers will be included in the review. MEDLINE Embase CINAHL the Cochrane Library Cochrane Central Register of Controlled Trials Google Scholar J-gate Dissertation Abstracts International ProQuest Dissertations and Theses are the main databases to be searched. The methodological merit of each study will be evaluated critically by two independent reviewers. Where possible studies will be combined in a statistical meta-analysis.

Abstract Droughts of various types are considered as a major threat to rainfed agriculture, because agricultural production is dependent on the spatio‐temporal distribution of rainfall. The rainfed regions of Pakistan, such as Potohar, have experienced several instances of drought since 2000. The most drought‐affected staple crop of the region is wheat, which ultimately affects regional food security. In this study, we examine the agricultural and the meteorological droughts in the Potohar region during 2000–2020, to create a drought risk map. This region comprises four districts, namely Attock, Chakwal, Jhelum and Rawalpindi. First, the agricultural and meteorological drought severity maps were created using rainfall data (meteorological data) and vegetation indices for three different periods (i.e., drought year, moderate drought year and normal year). The agricultural drought patterns and intensity were identified and evaluated using the MODIS products MOD09A1 and MOD11A2, while the meteorological droughts were identified using CHRIPS rainfall data. Afterwards, a combined drought risk map was generated by integrating the agricultural and meteorological adrought severity maps using a weighted overlay analysis. This drought risk map showed that Attock and Rawalpindi were expeiencing slight to no drought conditions, whereas the southwestern and central parts of Chakwal showed moderate drought conditions. Similarly, the western parts of Jhelum faced moderate drought conditions. Thus, the combined drought risk map may be a useful guide for decision makers in the local and provincial government. Using this map, they can identify adaptation practices in the drought‐prone areas of this region for enhancing agricultural productivity.

Artificial Neural Networks (ANNs) are becoming increasingly useful in numerous areas as they have a myriad of applications. Prior to using ANNs, the network structure needs to be determined and the ANN needs to be trained. The network structure is usually chosen based on trial and error. The training, which consists of finding the optimal connection weights and biases of the ANN, is usually done using gradient-descent algorithms. It has been found that swarm intelligence algorithms are favorable for both determining the network structure and for the training of ANNs. This is because they are able to determine the network structure in an intelligent way, and they are better at finding the most optimal connection weights and biases during the training as opposed to conventional algorithms. Recently, a number of swarm intelligence algorithms have been employed for optimizing different types of neural networks. However, there is no comprehensive survey on the swarm intelligence algorithms used for optimizing ANNs. In this paper, we present a review of the different types of ANNs optimized using swarm intelligence algorithms, the way the ANNs are optimized, the different swarm intelligence algorithms used, and the applications of the ANNs optimized by swarm intelligence algorithms.

Abstract Background Functional genomics uses unbiased systematic genome-wide gene disruption or analyzes natural variations such as gene expression profiles of different tissues from multicellular organisms to link gene functions to particular phenotypes. Functional genomics approaches are of particular importance to identify large sets of genes that are specifically important for a particular biological process beyond known candidate genes, or when the process has not been studied with genetic methods before. Results Here, we present a large set of genes whose disruption interferes with the function of the odoriferous defensive stink glands of the red flour beetle Tribolium castaneum. This gene set is the result of a large-scale systematic phenotypic screen using RNA interference applied in a genome-wide forward genetics manner. In this first-pass screen, 130 genes were identified, of which 69 genes could be confirmed to cause phenotypic changes in the glands upon knock-down, which vary from necrotic tissue and irregular reservoir size to irregular color or separation of the secreted gland compounds. Gene ontology analysis revealed that many of those genes are encoding enzymes (peptidases and cytochromes P450) as well as proteins involved in membrane trafficking with an enrichment in lysosome and mineral absorption pathways. The knock-down of 13 genes caused specifically a strong reduction of para-benzoquinones in the gland reservoirs, suggesting a specific function in the synthesis of these toxic compounds. Only 14 of the 69 confirmed gland genes are differentially overexpressed in stink gland tissue and thus could have been detected in a transcriptome-based analysis. However, only one out of eight genes identified by a transcriptomics approach known to cause phenotypic changes of the glands upon knock-down was recognized by this phenotypic screen, indicating the limitation of such a non-redundant first-pass screen. Conclusion Our results indicate the importance of combining diverse and independent methodologies to identify genes necessary for the function of a certain biological tissue, as the different approaches do not deliver redundant results but rather complement each other. The presented phenotypic screen together with a transcriptomics approach are now providing a set of close to hundred genes important for odoriferous defensive stink gland physiology in beetles.

Background: The novel Coronavirus Disease 2019 pandemic has had negative impact on healthcare professionals, such as the risk of stress due to pressure during pandemic and they were afraid of bringing the virus to their home. Purpose: To analyze factors associated with work stress level among healthcare professionals during Coronavirus Disease 2019 pandemic. Method: Survey with cross sectional design was conducted in July 2020. Data was online collected using the Google Forms platform was distributed to healthcare professionals throughout the Public Health Center in Sibolga City. The total of healthcare professionals who met the inclusion criteria and became the sample was 233 people. The data was presented as result of descriptive and analytical analysis using Chi-Square and Spearman test to see the relationship between independent and dependent variable. Result: The sampel was dominated by adults as much as 87.55%. The male was 12.02% and female was 87.98%. As many as 63.52% of healthcare professionals was low stress level, moderate stress level 23.18, and severe stress level 13.30%. Statistical analysis between showed that only the age (p-value = 0.03) and the history of Coronavirus Disease 2019 patients contact (p-value = 0.04) was significantly associated with stress levels. Conclusion: The age of healthcare professionals and the history of Coronavirus Disease 2019 patients contact significantly related to stress level of healthcare professionals in the Public Health Center during the Coronavirus Disease 2019 pandemic.

Introduction: Cancer patients are extremely vulnerable psychologically and may suffer a variety of psychological trauma. This can have a significant impact on their cancer resistance and recovery. The aim of this study was to investigate the transition process of crisis in cancer patients, considering the high number of cancer in the country. Methods: This study was conducted using a qualitative paradigm. In this study, narrative research approach and narrative interview technique was run in order to achieve the transition stages in crisis in cancer patients. During the interview with 14 cancer patients in Gonabad City, theoretical saturation was obtained. Data were analyzed using Strauss and Corbin (1990) comparative analysis. Results: Cancer patients went through 8 stages before accepting death. These stages included Disease shock, denial of disease, concealment, anger, depression, religious perception, acceptance of illness and acceptance of death. Conclusion: Due to the need to know the crisis process in people with cancer and the high number of patients, the results of this study can be used for people with the patients to deal with them properly, as well as for researchers, managers and planners to know more. The needs of cancer patients and evidence-based planning should be used.

The interaction between bacteria and insects can significantly impact a wide range of different areas because bacteria and insects are widely distributed around the globe. The bacterial-insect interactions have the potential to directly affect human health since insects are vectors for disease transmission, and their interactions can also have economic consequences. In addition, they have been linked to high mortality rates in economically important insects, resulting in substantial economic losses. MicroRNAs (miRNAs) are types of non-coding RNAs involved in regulating gene expression post-transcriptionally. The length of miRNAs ranges from 19 to 22 nucleotides. MiRNAs, in addition to their ability to exhibit dynamic expression patterns, have a diverse range of targets. This enables them to govern various physiological activities in insects, like innate immune responses. Increasing evidence suggests that miRNAs have a crucial biological role in bacterial infection by influencing immune responses and other mechanisms for resistance. This review focuses on some of the most recent and exciting discoveries made in recent years, including the correlation between the dysregulation of miRNA expression in the context of bacterial infection and the progression of the infection. Furthermore, it describes how they profoundly impact the immune responses of the host by targeting the Toll, IMD, and JNK signaling pathways. It also emphasizes the biological function of miRNAs in regulating immune responses in insects. Finally, it also discusses current knowledge gaps about the function of miRNAs in insect immunity, in addition to areas that require more research in the future.

Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is associated with significant morbidity and mortality. Congenital absence of the inferior vena cava (IVC) is reported in current literature as a rare risk factor for DVT. The presence of kidney and IVC abnormalities on computed tomography together with lower limb thrombosis is collectively referred to as KILT syndrome (Kidney and IVC Abnormalities with Leg Thrombosis), an extremely rare cause of extensive bilateral lower limb DVT.We present a case of KILT syndrome, diagnosed for the first time after the age of 60 years and the first case reported in the Irish population. The patient presented to the emergency department with unilateral limb pain with a prior history of provoked DVT. Clinical gestalt, a high Wells Score, and raised D-Dimer strongly supported a diagnosis of DVT. Lower limb duplex ultrasound confirmed bilateral external iliac and femoral vein thrombus, with computed tomography venography revealing an absent infrarenal IVC and atrophy of the left kidney. The medical team subsequently admitted the patient for therapeutic anticoagulation and investigation. After review by haematology, the patient was discharged on an indefinite duration of anticoagulation with follow-up with our coagulation services. In any patient with bilateral lower limb DVT, comprehensive assessment and investigation, with particular emphasis on imaging, is imperative to exclude rare associated conditions.

Optimization problems are usually solved using heuristic algorithms such as swarm intelligence algorithms owing to their ability of providing near-optimal solutions in a feasible amount of time. An example of an optimization problem is the training of artificial neural networks to obtain the most optimal connection weights. Artificial Neural Network (ANN), being the most prominent machine learning algorithm, has a multitude of applications in a myriad of areas. Recently, the use of ANNs has risen exponentially owing to its effective ability of making conclusions based on certain inputs. This ability is primarily achieved during the training phase of the ANN, which is a vital process prior to being able to use the ANN. Gradient descent-based algorithms, which are usually used for the training process, often encounter the problem of local optima, thus being unable to obtain the optimal connection weights of the ANN. Metaheuristic algorithms, including swarm intelligence algorithms, have been found to be a better alternative to train ANNs. The Dragonfly Algorithm (DA) is a swarm intelligence algorithm that has been found to be more effective than multiple swarm intelligence algorithms. However, despite having a good performance, it still suffers from low exploitation. In this paper, we propose to further improve the performance of DA by using hill climbing as a local search technique so as to enhance its low exploitation. The optimized DA algorithm is then used for training artificial neural networks which are employed for classification problems. Based on the experimental results, the optimized DA algorithm has higher effectiveness than the original DA and some other swarm intelligence algorithms as the ANNs trained by the optimized DA have a lower root mean squared error and a higher classification accuracy.

Introduction: The relationship between physicians and pharma industry is an old and significant one. This study was conducted to evaluate the relationship between doctors and sales representatives of different pharmaceutical companies. Moreover, it evaluates the conflict of interest arising from some unethical practices. Material & Methods: The study was conducted in the outpatient department of Ayub Teaching Hospital Abbottabad for a period of three months. The representatives of different pharmaceutical companies visiting the department of paediatrics were included in the study after informed consent. The data were recorded using a proforma having set of questions and then analysed using SSPS 24 software. Results: A total of 92 pharmaceutical company representatives were included in the study. Out of 92 representatives, 93.5% were given proper training. About 12% responded they openly gave incentives to doctors for boosting their company sales and 34.8% responded that doctors demanded personal gains from them. There is significant relationship between open incentive given to doctors and open demand by doctors (p = 0.005). Conclusion: Interaction of doctors with the pharmaceutical companies is complex and conflict of interest is there. On one hand pharmaceutical companies are not following code of conduct in promotion/sales of their products and on other hand a reasonable number of doctors are not following the ethical guidelines and are involved in malpractice.

OBJECTIVES Accidental poisoning in children is a serious public health problem in developing countries, especially where chemicals used in agriculture are ingested. Paraquat is a herbicide which is still used in Pakistan. We report a case of fatal unintentional paraquat ingestion by 3 years old child who could not survive. Lack of care in the storage of paraquat lead to the poisoning but initial inappropriate management was also one factor in the fatal outcome. Detailed history and provision of poison containers are important in the proper management of patients with poisoning.

In developing countries, accidental poisoning is a serious public health problem in children. But unintentional poisoning by parents in the form of medication is very rare. Ivermectin belongs to the group of Avermectins and is used in veterinary medicine and in use for human parasitic diseases. We report the case of 10 years old girl given ivermectin by her mother for an unspecified amount. The patient presented to the hospital with seizures and remained in a coma for five days. The patient was managed symptomatically and discharged home in stable condition with parents' counselling regarding child safety.

Objective Patients with coronavirus disease 2019 (COVID‐19) can progress to a state of unregulated inflammation called cytokine storm syndrome (CSS). We describe formation and operation of a COVID‐19 multidisciplinary consultation service that was allowed to individualize treatment for critically ill patients with COVID‐19 during the pandemic. Methods Institutional experts from different subspecialties formed a COVID‐19 CSS task force at Montefiore Medical Center, Bronx, NY. They agreed on a set of four clinical and six laboratory parameters that can help early identify COVID‐19 CSS. We describe the formation and implementation of the COVID‐19 task force. The case series description of the COVID‐19 CSS consultation cohort highlights consultation volume, baseline characteristics, clinical and laboratory parameters, and how biologic treatments were allocated to these patients. Results Between April 4,2020, and May 7,2020, the COVID‐19 CSS task force was formed, consisting of adult and pediatric rheumatologists and allergy and immunology physicians. The task force evaluated a total of 288 patients, of whom 197 (68%) were male, the median (interquartile range [IQR]) age was 62 (51‐70) years, 122 (42%) were Hispanic, and 88 (31%) were Black or African American. The common presenting symptoms in all referred patients were dyspnea (85%) and diarrhea (80%). Thirty‐one patients who received biologic therapy were younger, with a median (IQR) age of 53 (32‐63) years, as opposed to 62.5 (52‐70) years in the nonbiologic group (P = 0.008). A higher proportion receiving biologics was in the critical care setting (26 [84%] vs 151 [59%]; P = 0.006). Conclusion To the best of our knowledge, this is the first multidisciplinary collaborative effort to provide individualized patient recommendations for evaluation and treatment of patients with COVID‐19 who may have CSS. This working model helped to devise an approach that may have identified patients who were most likely to benefit from biologic therapy in the absence of evidence‐based guidelines.

The Traveling Salesman Problem (TSP) is a combinatorial optimization problem that is useful in a number of applications. Since there is no known polynomial-time algorithm for solving large scale TSP, metaheuristic algorithms such as Ant Colony Optimization (ACO), Bee Colony Optimization (BCO), and Particle Swarm Optimization (PSO) have been widely used to solve TSP problems through their high quality solutions. Several variants of PSO have been proposed for solving discrete optimization problems like TSP. Among them, the basic algorithm is the Swap Sequence based PSO (SSPSO), however, it does not perform well in providing high quality solutions. To improve the performance of the swap sequence based PSO, this paper introduces an Enhanced Swap Sequence based PSO (Enhanced SSPSO) algorithm by integrating the strategies of the Expanded PSO (XPSO) in the swap sequence based PSO. This is because although XPSO is only suitable for solving continuous optimization problems, it has a high performance among the variants of PSO. In our work, the TSP problem is used to model a package delivery system in the Kuala Lumpur area. The problem set consists of 50 locations in Kuala Lumpur. Our aim is to find the shortest route in the delivery system by using the enhanced swap sequence based PSO. We evaluate the algorithm in terms of effectiveness and efficiency while solving TSP. To evaluate the proposed algorithm, the solutions to the TSP problem obtained from the proposed algorithm and swap sequence based PSO are compared in terms of the best solution, mean solution, and time taken to converge to the optimal solution. The proposed algorithm is found to provide better solutions with shorter paths when applied to TSP as compared to swap sequence based PSO. However, the swap sequence based PSO is found to converge faster than the proposed algorithm when applied to TSP.

OBJECTIVE: To assess for the neurological complications and Bacille Calmette-Guerin (BCG) vaccination status of children with tuberculosis meningitis (TBM). METHODS: This retrospective study was conducted in Ayub Teaching Hospital, Abbottabad, Pakistan. Data of diagnosed case of TBM who received anti-tuberculous therapy from 2017 to 2020 was retrieved from records. Records of children, aged 6 months to 10 years of either gender were included and vaccination status was documented along with CT scan findings. Neurological complications in hospital and outcome were recorded as discharge, expiry and transfer to other hospital. RESULTS: Out of 40 patients, 17 (42.5%) were males and 23 (57.5%) females. Age ranged from 6 months to 8 years with mean age of 2.81±2.29 years. Weight ranged from 5 to 24 kg and mean weight was 10.36±4.96 kg. About 72.5% patients were

OBJECTIVES: The objective of the study was to evaluate factors associated with vaccine hesitancy and refusal at District Swabi, Khyber Pakhtunkhwa. METHODOLOGY: This cross-sectional study was conducted at a teaching hospital of Khyber Pakhtunkhwa District Swabi over a period of four months. Children between the ages of 9 months to 10 years from the local population admitted to the children ward/daycare centre were included in the study. Parents were inquired about vaccination status and in case of no vaccination or partial vaccination; then the reason was inquired after proper informed consent. Data were collected by using a structured proforma and analyzed using SPSS-24. RESULTS: A total of 828 children were included in this study. Out of these 492 (59.4%) were male and 336 (40.6%) were females. Of the total 828 children, 753 (90.9%) were vaccinated up to date, 48 (5.8%) were not vaccinated and 27 (3.3%) were partially vaccinated. Under vaccinated were 75 patients, 52% were left out due to misconception/beliefs, 6% patients were having issues due to living far away, 2.7% patients could not be vaccinated due to presence of other diseases and 37.3% due to lack of knowledge regarding vaccination. A significant correlation was found between the vaccination status of children and aforementioned reasons (p-value ≤0.001). CONCLUSION: The most common cause of not vaccinating children with polio vaccines was misconceptions/beliefs and lack of knowledge of the parents.

CONTEXT: Urethral stricture is a pathology involving the anterior urethra. The parameters to the surgical approach are precise measurement of stricture length and spongiofibrosis. Retrograde urethrography (RGU) is considered as the gold standard investigation. Its limitations are poor definition of stricture length and the detection of spongiofibrosis. Sonourethrography (SUG) detects stricture and accurately measures length and spongiofibrosis. AIM: The aim of this study is to compare the efficacy of SUG in the evaluation of anterior urethral strictures. SETTINGS AND DESIGN: The study design involves hospital-based 1-year observational study. SUBJECTS AND METHODS: One-year prospective observational study was conducted in the Department of Radio-Diagnosis at the KLE'S Dr. Prabhakar Kore Hospital and MRC, Belagavi. Thirty patients underwent RGU and SUG. Sensitivity, specificity, positive, and negative predictive values of SUG were calculated. Unpaired t-test was used to determine the length of the anterior urethral stricture. The values were compared with RGU and intra-operative results. The percentage of patients detected to have spongiofibrosis was computed. STATISTICAL ANALYSIS USED: Mean, standard deviation, and unpaired t-test were used for statistical analysis. RESULTS: The sensitivity and specificity of sonourethrogram as compared to retrograde urethrogram was found to be 92% and 100%, respectively, with positive and negative predictive values of 100% and 71.43%, respectively. Intra-operative stricture length correlated better with SUG with the determination of spongiofibrosis being an advantage. CONCLUSION: RGU is the best imaging modality, but SUG also provides similar results with benefits such as precise measurement of stricture length and degree of spongiofibrosis.

Introduction Newborn screening (NBS) is a test done shortly after birth to detect conditions that cause severe health problems if not treated early. An estimated 71% of babies worldwide are born in jurisdictions that do not have an established NBS programme. Guyana currently has no NBS programme and has established a partnership with Newborn Screening Ontario (NSO) to initiate screening.Objectives To assess the feasibility of implementing a NBS programme in Guyana for congenital hypothyroidism (CH) and haemoglobinopathies (HBG) and to report on screen positive rates and prevalence (Hardy-Weinberg equilibrium (HWE)) for CH and HBG.Methods Term, healthy Guyanese infants were evaluated (with consent) using heel prick dried blood spots (DBS) shortly after birth (closer to 24 hours of life). DBS samples were analysed at NSO. Screening test for CH was done using a human thyroid-stimulating hormone (hTSH) assay. Mean hTSH levels between the Guyanese sample and the Ontarian population were compared using Student’s t-test with an alpha of 0.05. Screening test for HBG was performed with a cation-exchange high-performance liquid chromatography.Results The pilot was conducted from 6 June 2016 to 22 September 2017. Georgetown Public Hospital Corporation recruited 2294 mothers/infants. Screen positive rate for CH in our sample was 0.0% (0/2038 infants). Mean TSH levels in Guyanese samples (1.7 µU/mL blood) was noticed to be significantly different than in the Ontarian population (4.3 µU/mL blood) (p

A two-month-old male infant presented with history of respiratory difficulty and got admitted with provisional diagnosis of pneumonia. On examination patient was having unilateral nasal hypoplasia and cyanosis with echocardiography showing truncus arteriosus. Detail history revealed that mother had valve replacement and she was taking warfarin during pregnancy. After initial management patient was referred to pediatric cardiac surgery and plastic surgery for further management. Parents were counseled regarding contraception and family planning.

Een interventie om financiële (opvoed-)vaardigheden te versterken. Het was tot in de puntjes doordacht, besproken en vormgegeven met sociaal werkers, een ervaringsdeskundige, studenten en onderzoekers. We voorzagen in alle randvoorwaarden volgens de theorie van Schaarste van Sendhil Mullainathan (2014) en noemden het ‘het Zakg€ldproject’. We wachtten met open armen op alle ouders en alle kinderen die een half jaar lang zakgeld en coaching wilden krijgen. Maar ze kwamen niet. Na wat verruimingen in de deelnamecriteria en extra werving meldde zich, welgeteld, één belangstellende ouder. Deze ervaring leerde ons dat een theoretisch zorgvuldig ontworpen interventie niet per se leidt tot een succes in de praktijk. Dit artikel beschrijft de gezamenlijke constructie van een interventie.

Malrotation of the gut can present at any age but the majority of patients present in neonatal period or early infancy. Most children present with a history of recurrent colicky abdominal pain, vomiting which can be bilious and failure to thrive. Delay in diagnosis leads to increase in mortality and morbidity. Here we present a series of three patients, one girl aged 6 years, one 10 months old boy and one 10 years old boy, who got admitted at our Pediatric Department in a one month period. Patients had a history of recurrent abdominal pain and occasional vomiting, seen and managed by multiple paediatricians and GP doctors with extensive diagnostic workup but never the accurate diagnosis was made. Thorough history was taken and examination done, planned work up done for diagnosis. High index of suspicion is needed in children presenting with recurrent pain in the abdomen. Targeted work-up should be done and patients be kept on follow-up for diagnosis of late presentation of congenital malrotation of the gut.

Sperm marking provides a key tool for reproductive biology studies, but it also represents a valuable monitoring tool for genetic pest control strategies such as the sterile insect technique. Sperm-marked lines can be generated by introducing transgenes that mediate the expression of fluorescent proteins during spermatogenesis. The homozygous lines established by transgenesis approaches are going through a genetic bottleneck that can lead to reduced fitness. Transgenic SIT approaches have mostly focused on Dipteran and Lepidopteran pests so far. With this study, we provide sperm-marked lines for the Coleopteran pest model organism, the red flour beetle Tribolium castaneum, based on the β2-tubulin promoter/enhancer driving red (DsRed) or green (EGFP) fluorescence. The obtained lines are reasonably competitive and were thus used for our studies on reproductive biology, confirming the phenomenon of ‘last-male sperm precedence’ and that the spermathecae are deployed for long-term sperm storage, enabling the use of sperm from first mating events even after secondary mating events for a long period of time. The homozygosity and competitiveness of the lines will enable future studies to analyze the controlled process of sperm movement into the long-term storage organ as part of a post-mating cryptic female choice mechanism of this extremely promiscuous species.

Optimization problems are prevalent in almost all areas and hence optimization algorithms are crucial for a myriad of real-world applications. Deterministic optimization algorithms tend to be computationally costly and time-consuming. Hence, heuristic and metaheuristic algorithms are more favoured as they provide near-optimal solutions in an acceptable amount of time. Swarm intelligence algorithms are being increasingly used for optimization problems owing to their simplicity and good performance. The Dragonfly Algorithm (DA) is one which is inspired by the swarming behaviours of dragonflies, and it has been proven to have a superior performance than other algorithms in multiple applications. Hence, it is worth considering its application to the traveling salesman problem which is a predominant discrete optimization problem. The original DA is only suitable for solving continuous optimization problems and, although there is a binary version of the algorithm, it is not easily adapted for solving discrete optimization problems like TSP. We have previously proposed a discrete adapted DA algorithm suitable for TSP. However, it has low effectiveness, and it has not been used for large TSP problems. In this paper, we propose an optimized discrete adapted DA by using the steepest ascent hill climbing algorithm as a local search. The algorithm is applied to a TSP problem modelling a package delivery system in the Kuala Lumpur area and to benchmark TSP problems, and it is found to have a higher effectiveness than the discrete adapted DA and some other swarm intelligence algorithms. It also has a higher efficiency than the discrete adapted DA.

There are many psychiatric consequences of severe and debilitating diseases. Psychiatric disorders are therefore commonly present after a physical illness. The purpose of this study was to investigate the process of acceptance of illness in patients with incurable diseases. The conceptual research framework was based on Kübler-Ross's theory of acceptance of illness. In this qualitative research, a guided approach to content analysis has been used. This study was carried out using semi structured interviews based on theoretical saturation with 15 patients with incurable diseases. The results of this study have shown that patients with incurable diseases have passed seven stages of death acceptance: shock disease, coping strategies, disease denial, anger, depression, referral group reactions, and acceptance of illness. Considering the need to recognize the process of accepting the disease in patients with incurable disease, the results of this study may be useful for those patients involved in treating the disease correctly. Furthermore, the results of this study can be used by researchers, managers, and planners to enhance their knowledge of incurable patient needs and evidence-based planning.

One posyandu constraint is the frequent change of posyandu cadres. This study aimed to determine the effect of posyandu basic information presentation through cadre refresher to cadre knowledge in Puskesmas Pelabuhan Sambas, Sibolga Sambas Sub-district, Sibolga City. This pre experimental study was used a one group pretest-postest design and the study was conducted from March 2017. The number of posyandu cadres who become respondents were 51 people in Puskesmas Pelabuhan Sambas. Method of this study was lecture and active discussion using slide show power point media. The presentation of posyandu basic information was 1 time performed with 3 hours duration. Before and after presentation, respondents were given a pre and post test questions. The results showed the level of education (p=0,000) and long time as a cadre (p=-,002) was significantly to increased knowledfe of posyandu cadres related to basic information posyandu. The presentation of posyandu basic information was increased knowledge of posyandu cadres (p=0,000). Need to do re-research with a longer duration of intervention and with other variables. Salah satu kendala yang dihadapi dalam pelaksanaan Posyandu adalah sering terjadinya pergantian kader posyandu. Penelitian bertujuan untuk mengetahui hubungan pemberian informasi dasar posyandu melalui kegiatan penyegaran kader terhadap pengetahuan kader di Puskesmas Pelabuhan Sambas, Kecamatan Sibolga Sambas, Kota Sibolga. Penelitian pra eksperimental ini menggunakan rancangan one group pretest-posttest dan dilaksanakan pada bulan Maret 2017. Jumlah kader posyandu yang menjadi responden sebanyak 51 orang di Wilayah Kerja Puskesmas Pelabuhan Sambas. Pemberian informasi dasar posyandu dilakukan sebanyak 1 kali dengan durasi 3 jam dengan metode ceramah dan tanya jawab menggunakan media gambar pada slide show power point. Sebelum dan setelah pemberian informasi, responden diberi pertanyaan pretest dan posttest. Hasil penelitian membuktikan tingkat pendidikan (p=0,000) dan lama menjadi kader (p=0,002) secara signifikan berhubungan dengan peningkatan pengetahuan kader posyandu terkait informasi dasar posyandu. Pemberian informasi dasar posyandu secara signifikan dapat meningkatkan pengetahuan kader posyandu (p=0,000). Disarankan untuk melakukan penelitian dengan durasi intervensi lebih panjang dan dengan variabel lain.

Titanium dioxide is semiconductor metal oxide having many applications in photocatalytic activities, cosmetics and in the food industry. It exists in three major crystalline forms: anatase, rutile and brookite. The solvents play a major role in the synthesis, stability and morphology of the metal oxide nanoparticles. It affects both the phase and particle size of metal oxide. The main focus of the present study is to establish the effects of solvent on the phase of TiO2 nanoparticle. Titanium dioxide (TiO2) nanoparticles have been synthesized by the sol-gel method using different solvents. The XRD results showed that the average crystallite size of all the samples was in the range of 5-25 nm. TiO2 nanoparticles prepared in different solvents gave different FT-IR peaks. AFM data clarified that the majority of samples showed spherical shape with average particle size ranging from 10-68 nm. The nanoparticles prepared in diethanolamine, acetic acid, and propionic acid solvents showed comparatively good antibacterial activity due to the rutile phase of the nanoparticles. the pH of the solvent also influences titanium dioxide structure and antibacterial properties

People have some rights to use it for living, patients are people and they should be aware of their rights. The purpose of this study was to determine the level of awareness and observation of patients’ rights and the factors affecting it from the perspective of the patients and nurses among all hospitalized patients and the nurses working at Bohlool hospital in Gonabad city. 100 patients and 100 nurses were selected as the statistical sample. Data were collected using the patients' rights questionnaire of bokai. The priority of the patients’ rights were as the followings: respect to patient privacy and secrecy principle (96% Moderate and Good), receiving desirable health services (92% Moderate and Good), access to an efficient complaints system (90% Moderate and Good), patient’s access to appropriate and adequate information (91% Moderate and Good), and the right to making choice and decision freely for the patients (76% Moderate and Good) in receiving hospital services, respectively. Also, there was a relationship between the level of awareness and observance of patients rights with demographic variables among the nurses. The results of the research showed that the lack of the patients’ awareness from their health and treatment rights and the enforcement lack of patients’ rights charter by the health and medical personnel can endanger health, life and safety of the patients. Therefore, the awareness and observance of these rights seemed necessary.