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Presents a letter to the editor concerning the identification of vitamin B12 deficiency as the cause of hyperhomocysteinaemia.

The role of pesticides in enhancing global agricultural production is magnificent. However, their unmanaged use threatens water resources and individual health. A significant pesticide concentration leaches to groundwater or reaches surface waters through runoff. Water contaminated with pesticides may cause acute or chronic toxicity to impacted populations and exert adverse environmental effects. It necessitates the monitoring and removing pesticides from water resources as prime global concerns. This work reviewed the global occurrences of pesticides in potable water and discussed the conventional and advanced technologies for the removal of pesticides. The concentration of pesticides highly varies in freshwater resources across the globe. The highest concentration of α-HCH (6.538 μg/L, at Yucatan, Mexico), lindane (6.08 μg/L at Chilka lake, Odisha, India), 2,4, DDT (0.90 μg/L, at Akkar, Lebanon), chlorpyrifos (9.1 μg/L, at Kota, Rajasthan, India), malathion (5.3 μg/L, at Kota, Rajasthan, India), atrazine (28.0 μg/L, at Venado Tuerto City, Argentina), endosulfan (0.78 μg/L, at Yavtmal, Maharashtra, India), parathion (4.17 μg/L, at Akkar, Lebanon), endrin (3.48 μg/L, at KwaZuln-Natl Province, South Africa) and imidacloprid (1.53 μg/L, at Son-La province, Vietnam) are reported. Pesticides can be significantly removed through physical, chemical, and biological treatment. Mycoremediation technology has the potential for up to 90% pesticide removal from water resources. Complete removal of the pesticides through a single biological treatment approach such as mycoremediation, phytoremediation, bioremediation, and microbial fuel cells is still a challenging task, however, the integration of two or more biological treatment approaches can attain complete removal of pesticides from water resources. Physical methods along with oxidation methods can be employed for complete removal of pesticides from drinking water., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction and Aim: Primary mediastinal B-cell lymphomas (PMBL) are aggressive B- cell lymphomas. Although the initial treatment models vary in PMBL, appropriate treatment methods are not known. We aim to show real-life data on health outcomes in adult patients with PMBL who received various type of chemoimmunotherapies in Turkey., Method: We analyzed the data of 61 patients who received treatments for PMBL from 2010 to 2020. The overall response rate (ORR), overall survival (OS) and progression-free survival (PFS) of the patients were evaluated., Results: 61 patients were observed in this study. The mean age of the study group was 38.4 ± 13.5 years. From among them, 49.2% of the patients were female (n = 30). For first-line therapy, 33 of them had received rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) regimen (54%). Twenty-five patients had received rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (DA-EPOCH-R) regimen. The ORR was 77%. The median OS and PFS were as follows: 25 months (95% CI: 20.4-29.4) and 13 months (95% CI: 8.6-17.3), respectively. The OS and PFS at 12 months were 91.3% and 50%, respectively. The OS and PFS at five years were 64.9% and 36.7%, respectively. Median follow-up time period was 20 months (IQR 8.5-38.5)., Conclusion: R-CHOP and DA-EPOCH-R showed good results in PMBL. These remain one of the best determined systemic treatment options for first-line therapy. Also, the treatment was associated with good efficacy and tolerability.

Carbon and its analogous nanomaterials are beneficial for toxic gas sensors since they are used to increase the electrochemically active surface region and improve the transmission of electrons. The present article addresses a detailed investigation on the potential of the monolayer PC 3 compound as a possible sensor material for environmentally toxic nitrogen-containing gases (NCGs), namely NH 3 , NO, and NO 2 . The entire work is carried out under the frameworks of density functional theory, ab-initio molecular dynamics simulations, and non-equilibrium Green's function approaches. The monolayer-gas interactions are studied with the van der Waals dispersion correction. The stability of pristine monolayer PC 3 is confirmed through dynamical, mechanical, and thermal analyses. The mobility and relaxation time of 2D PC 3 sensor material with NCGs are obtained in the range of 10 1 -10 4 cm 2 V -1 s -1 and 10 1 -10 3 fs for armchair and zigzag directions, respectively. Out of six possible adsorption sites for toxic gases on the PC 3 surface, the most prominent site is identified with the highest adsorption energy for all the NCGs. Considering the most stable configuration site of the NCGs, we have obtained relevant electronic properties by utilizing the band unfolding technique. The considerable adsorption energies are obtained for NO and NO 2 compared to NH 3 . Although physisorption is observed for all the NCGs on the PC 3 surface, NO 2 is found to convert into NO and O at 5.05 ps (at 300 K) under molecular dynamics simulation. The maximum charge transfer (0.31e) and work function (5.17 eV) are observed for the NO 2 gas molecule in the series. Along with the considerable adsorption energies for NO and NO 2 gas molecules, their shorter recovery time (0.071 s and 0.037 s, respectively) from the PC 3 surface also identifies 2D PC 3 as a promising sensor material for those environmentally toxic gases. The experimental viability and actual implications for PC 3 monolayer as NCGs sensor material are also confirmed by examining the humidity effect and transport properties with modeled sensor devices. The transport properties (I-V characteristics) reflect the significant sensitivity of PC 3 monolayer toward NO and NO 2 molecules. These results certainly confirm PC 3 monolayer as a promising sensor material for NO and NO 2 NCG molecules., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Necrotizing enterocolitis is one of the most common and worrying diseases in neonates, commonly shown in premature neonates, and is associated with significant mortality and morbidity. Necrotizing enterocolitis is characterized by intestinal mucosal injury that can progress to transmural bowel necrosis, and radiologically it can present with either pneumatosis intestinalis or portal venous gas. It is postulated to develop in an immunocompromised host in the setting of bacterial colonization, usually after administration of non-breast milk feed. Cow's milk allergy association with necrotizing enterocolitis has not been well determined, and the pathophysiology is still not clear. Necrotizing enterocolitis is very rare following living donor liver transplant. In our case, a 6-year-old boy who was doing well in the postoperative period had sudden worsening of general condition after he was started on milk feed. On evaluation and reexploration, he was diagnosed with necrotizing enterocolitis and later succumbed to death.

Background: The pretreatment ratio of neutrophils to lymphocytes (NLR) has been suggested as an indicator of poor outcome in various cancers. This study aimed to determine whether the preoperative NLR may be a predictor of survival in patients who underwent curative resection for colorectal cancer (CRC)., Materials and Methods: The records of 219 CRC patients underwent curative resection between 2008 and 2014 were retrospectively evaluated. NLR was calculated by preoperative complete blood counts. The effects of age, gender, anatomic location, histologic grade, lymphovascular invasion, pathological T, pathological N, and tumor-node-metastasis stages and NLR on disease-free survival (DFS) and overall survival (OS) were analyzed using univariate and multivariate analyses. The optimal cutoff value for NLR was determined using receiver operating characteristic curve analysis., Results: The best cutoff value of NLR was 2.8. Multivariate analysis showed that NLR was not a predictor of DFS. However, NLR was found as an independent prognostic factor for OS (Hazard ratio, 5.4; 95% confidence interval, 2.3-12.5; P = 0.0001)., Conclusion: A preoperative NLR of more than 2.8 might be an independent predictor for OS in patients with CRC. This simple and routinely available laboratory parameter may be used as a useful marker for identifying patients with a worse prognosis., Competing Interests: None

Background: Laparoscopic surgeries are a risk factor for raised intracranial **pressure and neurological complications. Even though rare, the consequences may be severe., Methods: One hundred and one patients of laparoscopic cholecystectomy were enrolled and were randomized into two groups: low-pressure 8 mm Hg (Group A) and high-pressure 14 mm Hg (Group B) carbon dioxide pneumoperitoneum during surgery. Fifty patients were in group A and 51 patients were in group B. Intracranial pressure was measured by measuring the optic nerve sheath diameter (ONSD) using ultrasound examination. Baseline ONSD was recorded followed by ONSD recording at various intervals: at the induction of anesthesia; 30 min, 45 min, at the end of surgery; and 30 min post surgery., Results: The groups were comparable in terms of demographics and comorbidities. The mean age of group A was 45 years and for group B it was 45.75 years. Most common indication for surgery was symptomatic gall stone disease. Baseline ONSD in group A was 0.427 ± 0.0459 mm, whereas it was 0.412 ± 0.0412 mm in group B. There was a significant rise of ONSD (p < 0.05) 30 min after induction of pneumoperitoneum and up to 30 min post anesthesia. In the low-pressure group 7 (14%) patients had a significant rise of ICP, whereas in the high-pressure group 20 (39%) patients had a significant rise of ICP (p < 0.05)., Conclusions: High-pressure pneumoperitoneum causes significant rise in intracranial pressure in comparison to low-pressure pneumoperitoneum during laparoscopic cholecystectomy, which can be monitored by ONSD measurement by ultrasound examination and is totally non-invasive.

In the present article, we report the thermoelectric properties of monolayer PC3 for the first time. The structural, vibrational, electronic and thermoelectric properties of PC3 are investigated in detail using a combination of density functional and Boltzman transport theory, and are compared to the carbon (graphene) and phosphorous (phosphorene) analogues. The results show that the PC3 monolayer is dynamically stable and robust upon oxygen contact as well. Also, PC3 is found to be an indirect band gap semiconductor in comparison to the zero gap carbon (graphene) and direct gap phosphorous (phosphorene) analogues. The effect of axial strains is also investigated on the electronic and thermoelectric properties of PC3. The present work reveals monolayer PC3 to be an excellent thermoelectric material with significant thermoelectric performance (ZT ∼ 1) for a large scale operating temperature range of 200-1200 K.

Introduction: Lifelong anticoagulation is the cornerstone of the chronic thromboembolic pulmonary hypertension (CTEPH) treatment regardless of the additional pulmonary endarterectomy, balloon pulmonary angioplasty, or medical treatment alone. Aim of this study was to evaluate the rate of oral anticoagulant preferences and document direct oral anticoagulants' (DOACs') safety, efficacy in the CTEPH population., Methods: Patients' demographic data obtained from database between September 2011 and April 2018. In-hospital events, death, venous thromboembolism (VTE) recurrence, bleeding events and anticoagulant therapy transition were recorded., Results: We reviewed 501 CTEPH patients who observed 9.0 ± 8.5 years. All-cause death, all bleeding, recurrent VTE was observed in 15.6%, 31% and 12%. Forty-one patients (8.2%) were diagnosed as inoperable. Of all, 15.2% of operable patients remained as residual. All-cause mortality rates were 13.8% (57 pts.) in the warfarin group as compared with 9.7% (13 pts.) in rivaroxaban group (HR: 1.61, 95% CI, 0.89-2.99; p : 0.11). Higher bleeding events occurred with warfarin group (27.1%) as compared with rivaroxaban (24.6%; HR: 1.28, 95% CI, 0.86-1.88; p : 0.22). Major bleeding was significantly higher with warfarin group (HR: 1.94, 95% CI, 1.05-3.62; p : 0.03). Subgroup analysis of all-cause death revealed that this significance dominated by the rate of death according to bleeding events; warfarin versus those seen with rivaroxaban (4.85% vs. 2.2%; HR: 4.75, 95% CI: 1.12-20.16; p  = 0.03). The rate of recurrent VTE was found 8.9% in the rivaroxaban group, 10.9% in warfarin group (HR: 1.21, 95% CI, 0.64-2.23; p : 0.55)., Conclusion: DOACs could be a safe and effective alternative for lifelong anticoagulant therapy in CTEPH patients. Rivaroxaban produced similar rates of thromboembolism and non-relevant bleeding compared to those associated with warfarin. The main difference was found with major bleeding that it was mainly associated with the death rate according to major bleeding. Using DOACs might be a more reasonable way to prevent bleeding events without increasing thromboembolic risk., (© The Author(s) 2020.)

Benign glandular enlargement of male breast is called gynaecomastia.Various drugs have been implicated as the cause. Most widely used HAART regimen TLE is enlisted in least common cause of gynaecomastia. A 42 yr old male diagnosed HIV seropositive since last 10 yrs was put on TLE regimen and he presented with gynaecomastia since 11 months. We hereby report this finding on HAART., (© Journal of the Association of Physicians of India 2011.)

The numbers of patients undergoing pancreaticoduodenectomy are increasing and considerable percentage is elderly patients. Pancreaticoduodenectomy is a major and complicated surgery. The morbidity and mortality following pancreaticoduodenectomy have significantly reduced in recent times; it still remains unclear in elderly patients. Applications of Enhanced Recovery after Surgery protocol have contributed for this better outcome. In this retrospective study, patients who underwent pancreaticoduodenectomy with Enhanced Recovery after Surgery protocol were included and divided into two groups (< 60 years vs ≥ 60 years). The "elderly patients" (≥ 60 years) were defined based on the WHO definition for Indian subcontinent. Outcomes were analyzed in terms of postoperative morbidity, mortality and length of hospital stay. Total 103 patients underwent pancreaticoduodenectomy during the study period (January 2012-December 2017). The mean age was 56.6 ± 10.32 years. Fifty-six (54.37%) patients were aged < 60 years (young group) and 47 (45.63%) patients were aged ≥ 60 years (elderly group). There was no difference between the groups in terms of age, gender, co-morbidity, preoperative drainage and diagnosis. There was no significant difference in the morbidity and mortality (p > 0.05). Delayed gastric emptying was the most common complication which was 25.24% (21% vs 23.41%). Pancreatic fistula rate was 13.59% (8.9% vs 12.76%) and hemorrhage was 4.85% (5.4% vs 4.3%). Mortality was 4.85%. Postoperative hospital stay was comparable (14.7 days vs 15.3 days) (p = 0.164). Pancreaticoduodenectomy is a safe surgical procedure in elderly patients in comparison to young patients. Application of Enhanced Recovery after Surgery protocol can improve the outcome further.

Background: Gallstone disease (GSD) and nonalcoholic fatty liver disease (NAFLD) are connected with a high prevalence in the general population and they share common risk factors for their occurrence. Limited literature with inconsistent results is available, suggesting a potential association between these lifestyle-induced diseases. Liver biopsy is the gold standard for diagnosing NAFLD. The aim of this study was (1) to identify the prevalence of asymptomatic NAFLD or NASH in liver biopsy; (2) to identify the association of hypercholesterolemia with NAFLD in patients undergoing laparoscopic cholecystectomy (LC)., Methods: This is a prospective observational study conducted on patients who underwent LC for symptomatic gallstones in the Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India, from 1st July 2013 to 31st December 2014. All included patients had ultrasonography (USG) and the following parameters tested: serum triglycerides (TG), cholesterol, low density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C). A wedge liver biopsy was obtained from free edge of the right liver lobe during LC and all biopsy specimens were analyzed by a single pathologist., Results: Among 101 patients included in the study, dyslipidemia was present in 49.50%. There was no association between NAFLD and serum cholesterol, TG or LDL-C (P, 0.428, 0.848, 0.371 respectively). NAFLD was confirmed in liver biopsy in 21.8% of patients but none had fibrosis or cirrhosis on biopsy. No complications were observed following liver biopsy., Conclusions: Liver biopsy during LC gives an opportunity to diagnose the disease at an early and reversible stage. It is feasible, safe and cost effective.

Objective: Although there is a significant willingness to respond to disasters, a review of post-event reports following incidents shows troubling repeated patterns with poorly integrated response activities and response managers inadequately trained for the requirements of disasters. This calls for a new overall approach in disaster management., Methods: An in-depth review of the education and training opportunities available to responders and disaster managers has been undertaken, as well as an extensive review of the educational competencies and their parent domains identified by subject matter experts as necessary for competent performance., Results: Seven domains of competency and competencies that should be mastered by disaster mangers were identified. This set of domains and individual competencies was utilized to define a new and evolving curriculum. In order to evaluate and assess the mastery of each competency, objectives were more widely defined as activities under specific topics, as the measurable elements of the curriculum, for each managerial level., Conclusions: This program enables interagency cooperation and collaboration and could be used to increase and improve decision-makers' understanding of disaster managers' capabilities; at the strategic/tactical level to promote the knowledge and capability of the disaster managers themselves; and as continuing education or further career development for disaster managers at the operational level. (Disaster Med Public Health Preparedness. 2016;10:854-873).

Objective: The aim of this study was to examine the role of sentinel lymph node biopsy (SLNB) on long-term disease outcome in patients with intermediate-thickness primary cutaneous melanomas., Materials and Methods: Forty patients with intermediate-thickness melanomas, defined as 1.0-4.0 mm, underwent SLNB between 1998 and 2011. The disease-free survival (DFS), overall survival (OS) and prognostic factors were analyzed., Results: Median age was 53 years (range: 24-74 years). Median Breslow thickness was 2.8 mm (range: 1.0-4.0 mm) and 27.5% were ulcerated melanomas. Median follow-up time was 70 months (range: 23-168 months). The number of patients with sentinel lymph node (SLN)-positive was 9 (22.5%) and completion lymph node dissection was performed in all of these patients. Ten patients (25%) developed distant and locoregional recurrence; 4 in the SLN-positive group (4/9; 45%) and 6 in the SLN-negative group (6/31; 19%), P < 0.042. In the SLN-negative group, one patient developed regional node recurrence; false-negative rate was 10%. SLN positivity and ulceration were independent prognostic factors for DFS in multivariate analysis (hazard ratio [HR] of 4.6, and 10.5, respectively; P < 0.011). For OS SLN positivity, ulceration and Breslow thickness were found to be the significant prognostic factors (HR of 5.4, 8.5 and 5.0, respectively; P < 0.024). Ten-year DFS and OS for SLN-negative and SLN-positive patients were 71%, 47% (P < 0.003), and 80%, 55% (P < 0.005), respectively., Conclusion: This study shows that survival rates are worse in the SLN-positive patients according to the long-term follow-up data. Ulceration and Breslow thickness also have significant effects on long-term survival in patients with intermediate-thickness primary cutaneous melanomas.

Objective: The aim of this study is to investigate if there was a change in time in terms of age at diagnosis, menopausal status, pathologic tumor size, lymphatic metastasis and pathologic stage in patients with surgical treatment for breast carcinoma., Material and Methods: The clinical and pathological characteristics of 1223 patients with breast carcinoma who underwent surgical treatment between January 1994 and December 1998, and of 1346 patients who underwent surgical treatment with the same diagnosis between January 2004 and December 2008 were retrospectively reviewed., Results: The median age at diagnosis was 48 (20-78) years during the first period, and 50 (20-91) years during the second period. While 27% of patients were 40 years of age or younger in the first period, this ratio decreased to 20% during the second period (p=0.0001). The rate of premenopausal patients was 54% in the first period and 46% in the second period (p=0.0001). The median tumor size at diagnosis was 3 cm at the first period, and 2.5 cm at the second period. The number of patients with tumor size ≤2 cm increased in time from 391 (32%) to 531 (39%) (p=0.0001). Among young patients (aged ≤40 years), the number of patients with tumor size 2 cm or smaller were 81 (24.5%) and 92 (33.8%) at the first and second periods, respectively (p=0.001). Lymphatic metastases rate of patients aged ≤40 years was higher than patients aged >40 years, in both study periods (p=0.0001). The number of patients staged as pN1 at the first period increased from 356 (50.8%) to 441 (56.3%) at the second interval, while those staged as pN3 decreased from 251 (35.8%) to 175 (22.3%) (p=0.0001)., Conclusion: It may be concluded that recently, breast cancer is diagnosed at older ages, the rate of young and premenopausal patients and size on diagnosis has decreased, and breast-conserving surgery is used more often.

Objective: Unremitting natural disasters, deliberate threats, pandemics, and humanitarian suffering resulting from conflict situations necessitate swift and effective response paradigms. The European Union's (EU) increasing visibility as a disaster response enterprise suggests the need not only for financial contribution but also for instituting a coherent disaster response approach and management structure. The DITAC (Disaster Training Curriculum) project identified deficiencies in current responder training approaches and analyzed the characteristics and content required for a new, standardized European course in disaster management and emergencies., Methods: Over 35 experts from within and outside the EU representing various organizations and specialties involved in disaster management composed the DITAC Consortium. These experts were also organized into 5 specifically tasked working groups. Extensive literature reviews were conducted to identify requirements and deficiencies and to craft a new training concept based on research trends and lessons learned. A pilot course and program dissemination plan was also developed., Results: The lack of standardization was repeatedly highlighted as a serious deficiency in current disaster training methods, along with gaps in the command, control, and communication levels. A blended and competency-based teaching approach using exercises combined with lectures was recommended to improve intercultural and interdisciplinary integration., Conclusion: The goal of a European disaster management course should be to standardize and enhance intercultural and inter-agency performance across the disaster management cycle. A set of minimal standards and evaluation metrics can be achieved through consensus, education, and training in different units. The core of the training initiative will be a unit that presents a realistic situation "scenario-based training."

Objective: Gastric cancer is often diagnosed at an advanced stage and surgery alone cannot guarantee satisfactory results. Both chemoradiotherapy (CRT) and chemotherapy (CT) are used in postoperative therapy. However, it is controversial whether CRT or CT is better after D2 lymphadenectomy. In this study we investigated the efficacy of adjuvant CRT versus CT in stage III gastric cancer patients treated with R0 gastrectomy and D2 lymph node dissection., Patients and Methods: Data from 92 patients diagnosed with gastric adenocarcinoma and treated with surgery followed by adjuvant treatment were retrospectively analyzed. Patients were classified into two groups depending on type of adjuvant treatment such as CT (Arm A) and CRT (Arm B)., Results: Twenty-one patients in Arm A and 71 patients in Arm B were included. Median age at diagnosis was 60 years. The median follow-up time was 30 months. No difference in local recurrence (14.3 vs 15.7%, P = 0.89), peritoneal recurrence (29.4 vs 23.5%, P = 0.62), and distant metastases rates (57.1 vs 45.1%, P = 0.42) were observed between the arms. Disease-free survival (DFS) rates did not differ between Arms A and B (26 and 22 months, P = 0.80) respectively. Median overall survival (OS) in Arm A was 29 months and it was 32 months for Arm B. There was no difference in 5-year OS and DFS between Arms A and B (23.8 vs 34.4%, P = 0.74; and 24.1 vs 32.9%, P = 0.80)., Conclusions: Adjuvant CRT does not appear to improve clinical outcomes compared to adjuvant CT in this study and prospective studies are required to confirm these results.

Although the coexistence of hairy cell leukemia with sarcoidosis has been reported in a few cases in the literature, in our case the patient had been diagnosed and followed about 10 years with sarcoidosis and massive splenomegaly. It has been demonstrated that T helper 1 cells exist in organs influenced by sarcoidosis. These cells produce IL-2 and IFN-γ and induce a nonspecific inflammatory response and granuloma formation. Also these cytokines may play a role in the development of hairy cell leukemia.Key words: hairy cell leukemia -  sarcoidosis - massive splenomegaly.

Purpose: This study aimed to identify the effect of breast cancer subtype on nonsentinel lymph node (NSLN) metastasis in patients with a positive sentinel lymph node (SLN)., Methods: The records of 104 early breast cancer patients with a positive SLN between April 2009 and September 2013 were retrospectively evaluated. All patients underwent axillary lymph node dissection. The effects of the tumor subtype (luminal A, luminal/HER2+, human epidermal growth factor receptor 2 [HER2] overexpression, and triple-negative) and other clinicopathological factors on NSLN metastasis were examined by univariate and multivariate statistical analyses., Results: Fifty of 104 patients (48%) exhibited NSLN metastasis. Univariate and multivariate analyses revealed that tumor size and the ratio of positive SLNs were significant risk factors of NSLN metastasis in patients with a positive SLN. The rate of NSLN metastasis was higher in patients with luminal/HER2+ and HER2 overexpression subtypes than that in patients with other subtypes in the univariate analysis (p<0.001). In the multivariate analysis, both patients with luminal/HER2+ (p<0.006) and patients with HER2 overexpression (p<0.031) subtypes had a higher risk of NSLN metastasis than patients with the luminal A subtype., Conclusion: Subtype classification should be considered as an independent factor when evaluating the risk of NSLN metastasis in patients with a positive SLN. This result supports the development of new nomograms including breast cancer subtype to increase predictive accuracy.

I introduce an organizational model describing the response of the hospital emergency department. The hybrid simulation/analytical model (called a "metamodel") can estimate a hospital's capacity and dynamic response in real time and incorporate the influence of damage to structural and nonstructural components on the organizational ones. The waiting time is the main parameter of response and is used to evaluate the disaster resilience of health care facilities. Waiting time behavior is described by using a double exponential function and its parameters are calibrated based on simulated data. The metamodel covers a large range of hospital configurations and takes into account hospital resources in terms of staff and infrastructures, operational efficiency, and the possible existence of an emergency plan; maximum capacity; and behavior both in saturated and overcapacitated conditions. The sensitivity of the model to different arrival rates, hospital configurations, and capacities and the technical and organizational policies applied during and before a disaster were investigated. This model becomes an important tool in the decision process either for the engineering profession or for policy makers.

Introduction: Unacceptable practices in the delivery of international medical assistance are reported after every major international disaster; this raises concerns about the clinical competence and practice of some foreign medical teams (FMTs). The aim of this study is to explore and analyze the opinions of disaster management experts about potential deficiencies in the art and science of national and FMTs during disasters and the impact these opinions might have on competency-based education and training., Method: This qualitative study was performed in 2013. A questionnaire-based evaluation of experts' opinions and experiences in responding to disasters was conducted. The selection of the experts was done using the purposeful sampling method, and the sample size was considered by data saturation. Content analysis was used to explore the implications of the data., Results: This study shows that there is a lack of competency-based training for disaster responders. Developing and performing standardized training courses is influenced by shortcomings in budget, expertise, and standards. There is a lack of both coordination and integration among teams and their activities during disasters. The participants of this study emphasized problems concerning access to relevant resources during disasters., Conclusion: The major findings of this study suggest that teams often are not competent during the response phase because of education and training deficiencies. Foreign medical teams and medically related nongovernmental organizations (NGOs) do not always provide expected capabilities and services. Failures in leadership and in coordination among teams are also a problem. All deficiencies need to be applied to competency-based curricula.

Introduction: Education and training are key elements of disaster management. Despite national and international educational programs in disaster management, there is no standardized curriculum available to guide the European Union (EU) member states. European- based Disaster Training Curriculum (DITAC), a multiple university-based project financially supported by the EU, is charged with developing a holistic and highly-structured curriculum and courses for responders and crisis managers at a strategic and tactical level. The purpose of this study is to qualitatively assess the prevailing preferences and characteristics of disaster management educational and training initiatives (ETIs) at a postgraduate level that currently exist in the EU countries., Methods: An Internet-based qualitative search was conducted in 2012 to identify and analyze the current training programs in disaster management. The course characteristics were evaluated for curriculum, teaching methods, modality of delivery, target groups, and funding., Results: The literature search identified 140 ETIs, the majority (78%) located in United Kingdom, France, and Germany. Master level degrees were the primary certificates granted to graduates. Face-to-face education was the most common teaching method (84%). Approximately 80% of the training initiatives offered multi- and cross-disciplinary disaster management content. A competency-based approach to curriculum content was present in 61% of the programs. Emergency responders at the tactical level were the main target group. Almost all programs were self-funded., Conclusion: Although ETIs currently exist, they are not broadly available in all 27 EU countries. Also, the curricula do not cover all key elements of disaster management in a standardized and competency-based structure. This study has identified the need to develop a standardized competency-based educational and training program for all European countries that will ensure the practice and policies that meet both the standards of care and the broader expectations for professionalization of the disaster and crisis workforce.

A 65 years old man was admitted with multiple lymphadenopathy, weight loss, night sweats and fatigue for 2 months. He had been treated for bladder cancer 2 years ago. Leukocyte count was 37.9 x10(9)/l. Peripheral blood smear had 91% lymphocytes. Lymphocytes had large nuclei with prominent nucleoli, heterogeneous appearance, and large cytoplasm with hairy projections. Flow cytometric immunophenotyping revealed CD20, CD22, CD24, CD45 and HLA-DR positivity. Atypical lymphocytes were stained with tartrate resistant acid phosphatase. Increased metabolic activity was detected in multiple lymph nodes, bone marrow and extremely enlarged spleen with positron emission tomography-computed tomography. Excisional biopsy of the left axillary lymph node revealed infiltration with diffuse B-cell leukemia/lymphoma. Immunohistochemistry showed CD20 positive atypical cells with weak expression of CD11c. The patient was diagnosed as a case of variant hairy cell leukemia and cladribine was administered. A probable second primary malignancy should be kept in mind in cases with a defined malignancy in the presence of unusual symptoms.

Objective: Anal squamous cell carcinomas are one of the rare cancer types. Due to the developments in the past 35 years, surgery is no longer the first treatment of choice. The aim of this study was to retrospectively examine the outcomes of 24 patients treated in a single center in the last 21 years in terms of applied treatment, local relapse, distant metastasis, post-treatment complications, and survival., Material and Methods: Data obtained from 24 anal squamous cell carcinoma patients, who were treated in Ankara Oncology Research and Education Hospital between 1990 and 2010, were retrospectively evaluated., Results: Of the 24 patients, 16 had anal canal squamous cell carcinoma and eight had perianal squamous cell carcinoma. All of the patients with anal canal squamous cell carcinoma (n=16) received chemoradiotherapy. Three of these patients who did not respond to treatment, underwent abdominoperineal resection. The patients with perianal squamous cell tumors were treated by local excision. During the follow -ups, seven patients experienced local relapse, and one patient had distant organ metastasis. Only one patient died. Five-year disease free survival rate was found as 66%., Conclusion: Our findings suggest that the first alternative in the treatment of anal squamous cell tumors should be chemoradiotherapy; and surgery seems to be the appropriate approach for the non-responsive and relapsing cases.

The important thing in a patient in whom platelet values were detected to be greater than normal is whether thrombocytosis is a reactive phenomenon due to a different pathology or due to a clonal hematological pathology. In this case report, reactive thrombocytosis observed in a case with subclinical hypothyroidism due to Hashimoto's thyroiditis is reported; and according to our literature review, this is the first reported case of reactive thrombocytosis due to Hashimoto's thyroiditis and/or subclinical hypothyroidism. A 31-year-old man without any complaint was admitted to the Hematology Department for thrombocytosis which was detected in his routine follow-up. He had been using thyroid hormone replacement for 2 years because of hypothyroidism as Hashimoto's thyroiditis was earlier diagnosed. Due to miscommunication, he stopped his medication levothyroxine 0.1 mg/day 2 weeks in advance and he was still off-drug on admission. Platelet count was 715×10/l in the first admission center. Subclinical hypothyroidism diagnosis was made with the present findings and thyroid hormone replacement therapy was again commenced gradually. Platelet counts and thyroid-stimulating hormone value were normal 6 weeks later. As a result, before making diagnosis of thrombocytosis related to myeloproliferative disease or myelodysplastic syndromes, secondary causes should be investigated carefully.

Background & Objectives: Galantamine, a centrally-acting cholinesterase inhibitor, has been used in the treatment of mild-to-moderate dementia of Alzheimer disease. Increased mortality, mainly due to cardiovascular events, was observed in placebo-controlled trials of galantamine. Several studies have evaluated the efficacy of galantamine in dementia, it is not clear whether it has an effect on platelet function. It is important to clarify this effect, because it may be related to thrombotic tendency or bleeding diathesis. This study was aimed to investigate the effect of galantamine on platelet aggregation in whole blood from healthy, elderly subjects., Methods: Fifteen healthy (mean age 76.8 ± 7.2 yr) volunteers were included in the study. Three concentrations of galantamine solution (20, 40 and 80 ng/μl) were prepared. Each concentration of galantamine solution and control diluent without galantamine were incubated with whole blood. After incubation, aggregation responses were evaluated with ADP (5 μM) and collagen (2 μg/ml) in platelet-rich plasma., Results: Compared to control, pre-incubation with all dilutions of galantamine had no detectable effect on platelet aggregation response induced by ADP and collagen. Galantamine also had no detectable effect on platelet aggregation in a dose-dependent manner., Interpretation & Conclusions: This in vitro study suggested that galantamine administration had no effect on platelet aggregation in the clinically relevant doses.

Mucormycosis (Zygomycosis) is a rare, invasive, opportunistic fungal infection of the paranasal sinuses, caused by a fungus of the order Mucorales. We report a case of rhinoorbital mucormycosis caused by Rhizopus oryzae in an acute lymphoblastic leukemia patient and review the 79 Mucormycosis cases reported in the last decade from Turkey. In our case, the diagnosis was made with endoscopic appearance, computerized tomography of the paranasal sinuses, and culture of the surgical materials. Following aggressive surgical debridement and parenteral amphotericin B therapy, the patient recovered completely. In Turkish literature, rhinocerebral manifestations were the most common form of the mucormycosis (64 cases), followed by pulmonary form (6 cases). The most common risk factor was hematologic malignancies (32 cases) and diabetes mellitus (32 cases), similar to those reported from the rest of the world. The etiologic agents responsible for the review cases were Rhizopus sp., Mucor spp., Rhizomucor spp., Rhizopus oryzae, Mucor circinelloides, and Lichtheimia corymbifera. Although various treatment modalities were used, amphotericin B was the mainstay of therapy. Mortality rate was found to be 49.4% in review cases. It seems that strong clinical suspicion and early diagnosis, along with aggressive antifungal therapy and endoscopic sinus surgery, have great importance for better prognosis in mucormycosis.

Background: Many studies have investigated the association between the molecular subtypes of breast cancer and survival. The aim of this study was to identify the effects of intrinsic subtypes of breast cancer and the other clinicopathological factors on postmastectomy locoregional recurrence (LRR) in patients with early breast cancer., Methods: The records of 1,195 consecutive early breast cancer patients treated with modified radical mastectomy between 2004 and 2008 were retrospectively evaluated. The effects of intrinsic subtypes of the tumor (luminal A, luminal B, HER2-overexpressing, and triple-negative) and classical clinicopathological factors on LRR were identified by univariate and multivariate statistical analyses., Results: The median follow-up time was 44 months, and 16 (1.3%) patients experienced a LRR during this period. In univariate analysis, the intrinsic subtypes of breast cancer had a significant effect on LRR (p = 0.002). In multivariate analysis, only extranodal invasion and estrogen receptor (ER) status were significant predictors of LRR (p = 0.003 and 0.0001, respectively), whereas intrinsic subtypes did not reveal a significant relationship with LRR (p = 0.57; hazard ratio, 2.9; 95% confidence interval, 0.2-4.7)., Conclusions: The results of this study suggest that the extranodal invasion and negative ER status should potentially be considered when evaluating the risk of LRR. The predictive power of intrinsic subtypes for LRR is less than that of classical pathological indicators. This information may be useful in planning management of LRR in early breast cancer patients treated with mastectomy.