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Introduction: Situs inversus totalis (SIT), a rare congenital disorder, involves complete reversal of the heart's position and mirrored arrangement of visceral organs. Early diagnosis is crucial for managing complications like transposition of the great vessels and Kartagener syndrome, marked by bronchiectasis and sinusitis due to ciliary dysfunction. Case presentation: A 52-year-old male with diabetes mellitus presented with large amounts of watery diarrhea, vomiting, dizziness, and palpitations. He managed his diabetes with 70 units of insulin daily and had a history of chronic obstructive pulmonary disease. Physical examination revealed hypotension, tachycardia, and a right-sided apex beat. Investigations, including chest X-ray, ultrasound, and ECG, confirmed dextrocardia with situs inversus and hypovolemic shock secondary to acute gastroenteritis. The patient responded well to treatment and was discharged on the second day, continuing diabetic management. Discussion: SIT is a genetically determined anomaly with an incidence ranging from 1:35 000 to 1:1400, averaging 1:10 000, with a higher prevalence in males. Many patients are asymptomatic, with the condition often detected incidentally. Diagnostic imaging techniques, including chest radiography, CT scans, MRI, and ultrasonography, are crucial in confirming SIT. ECG findings, such as right-axis deviation and reversed QRS complexes, are valuable in diagnosing dextrocardia. Patient education is essential to empower individuals with SIT to navigate their healthcare, prevent complications, and reduce anxiety. Conclusion: SIT poses diagnostic challenges due to its incidental discovery. Accurate diagnosis relies on thorough imaging and clinical evaluation. Patient education is vital for informed care and anxiety reduction. Case reviews underscore the importance of healthcare providers' readiness to diagnose SIT effectively despite unrelated symptoms. Resumen: Introducción: Situs inversus totalis, un trastorno congénito raro, implica la inversión completa de la posición del corazón y la disposición en espejo de los órganos viscerales. El diagnóstico temprano es crucial para manejar complicaciones como la transposición de los grandes vasos y el síndrome de Kartagener, caracterizado por bronquiectasias y sinusitis debido a la disfunción ciliar. Presentación del Caso: Un hombre de 52 años con diabetes mellitus presentó grandes cantidades de diarrea acuosa, vómitos, mareos y palpitaciones. Controlaba su diabetes con 70 unidades de insulina diarias y tenía antecedentes de EPOC. El examen físico reveló hipotensión, taquicardia y un latido apical en el lado derecho. Las investigaciones, incluyendo radiografía de tórax, ecografía y ECG, confirmaron dextrocardia con situs inversus y choque hipovolémico secundario a gastroenteritis aguda (AGE). El paciente respondió bien al tratamiento y fue dado de alta al segundo día, continuando con el manejo de la diabetes. Discusión: SIT es una anomalía determinada genéticamente con una incidencia que varía de 1:35,000 a 1:1400, promediando 1:10,000, con una mayor prevalencia en hombres. Muchos pacientes son asintomáticos, con la condición a menudo detectada incidentalmente. Las técnicas de diagnóstico por imagen, incluyendo radiografía de tórax, tomografías computarizadas, resonancia magnética y ultrasonografía, son cruciales para confirmar SIT. Los hallazgos del ECG, como la desviación del eje derecho y los complejos QRS invertidos, son valiosos para diagnosticar la dextrocardia. La educación del paciente es esencial para empoderar a las personas con SIT a navegar su atención médica, prevenir complicaciones y reducir la ansiedad. Conclusión: Situs inversus totalis (SIT) presenta desafíos diagnósticos debido a su descubrimiento incidental. Un diagnóstico preciso depende de una evaluación clínica e imagenológica exhaustiva. La educación del paciente es vital para una atención informada y la reducción de la ansiedad. Las revisiones de casos subrayan la importancia de que los proveedores de atención médica estén preparados para diagnosticar SIT de manera efectiva a pesar de los síntomas no relacionados.

Abstract Background UK national clinical guidance recommends that men with prostate cancer on androgen deprivation therapy are offered twice weekly supervised aerobic and resistance exercise to address iatrogenic harm caused by treatment. Very few NHS trusts have established adequate provision of such services. Furthermore, interventions fail to demonstrate sustained behaviour change. The STAMINA lifestyle intervention offers a system-level change to clinical care delivery addressing barriers to long-term behaviour change and implementation of new prostate cancer care pathways. This trial aims to establish whether STAMINA is clinically and cost-effective in improving cancer-specific quality of life and/or reducing fatigue compared to optimised usual care. The process evaluation aims to inform the interpretation of results and, if the intervention is shown to benefit patients, to inform the implementation of the intervention into the NHS. Methods Men with prostate cancer on androgen deprivation therapy (n = 697) will be identified from a minimum of 12 UK NHS trusts to participate in a multi-centre, two-arm, individually randomised controlled trial. Consenting men will have a ‘safety to exercise’ check and be randomly allocated (5:4) to the STAMINA lifestyle intervention (n = 384) or optimised usual care (n = 313). Outcomes will be collected at baseline, 3-, 6- and 12-month post-randomisation. The two primary outcomes are cancer-specific quality of life and fatigue. The parallel process evaluation will follow a mixed-methods approach to explore recruitment and aspects of the intervention including, reach, fidelity, acceptability, and implementation. An economic evaluation will estimate the cost-effectiveness of the STAMINA lifestyle intervention versus optimised usual care and a discrete choice experiment will explore patient preferences. Discussion The STAMINA lifestyle intervention has the potential to improve quality of life and reduce fatigue in men on androgen deprivation therapy for prostate cancer. Embedding supervised exercise into prostate cancer care may also support long-term positive behaviour change and reduce adverse events caused by treatment. Findings will inform future clinical care and could provide a blueprint for the integration of supervised exercise and behavioural support into other cancer and/or clinical services. Trial registration ISRCTN 46385239, registered on 30/07/2020. Cancer Research UK 17002, retrospectively registered on 24/08/2022.

This investigation seeks to explore the influences of renewable energy and foreign direct investment (FDI) on Egypt's economy. Due to the function of FDI in promoting GDP expansion and renewable energy technology advancement, it is crucial to analyze the nexus between the economy, FDI, and green power. Egypt's annual data from 1990 to 2021 were employed in this research. By applying unit root tests, the data's stationarity was evaluated. The autoregressive distributed lag (ARDL) method was used to look into the connection between the variables in the long- and the short-run. Moreover, the reliability of the findings was reviewed using dynamic ordinary least squares (DOLS), fully modified ordinary least squares (FMOLS), and canonical cointegration regression (CCR) methodologies. As per the ARDL conclusions, an intensification of 1% in both renewable energy usage and FDI will be responsible for a boost of 1.02% and 1.87% in GDP over the long term, moreover to an upsurge of 0.54% and 1.11% over the short run. These outcomes suggest appropriate suggestions for the Egyptian government toward equitable development through promoting sustainable innovation in energy, improving FDI, and advancing sustainable economic expansion.

[This corrects the article DOI: 10.1371/journal.pone.0249277.].

BackgroundElicitation of patients’ preferences is an integral part of shared decision-making, the recommended approach for prostate cancer decision-making. Existing decision aids for this population often do not specifically focus on patients’ preferences. Healium is a brief interactive web-based decision aid that aims to elicit patients’ treatment preferences and is designed for a low health literate population. ObjectiveThis study used a randomized controlled trial to evaluate whether Healium, designed to target preference elicitation, is as efficacious as Healing Choices, a comprehensive education and decision tool, in improving outcomes for decision-making and emotional quality of life. MethodsPatients diagnosed with localized prostate cancer who had not yet made a treatment decision were randomly assigned to the brief Healium intervention or Healing Choices, a decision aid previously developed by our group that serves as a virtual information center on prostate cancer diagnosis and treatment. Assessments were completed at baseline, 6 weeks, and 3 months post baseline, and included decisional outcomes (decisional conflict, satisfaction with decision, and preparation for decision-making), and emotional quality of life (anxiety/tension and depression), along with demographics, comorbidities, and health literacy. ResultsA total of 327 individuals consented to participate in the study (171 were randomized to the Healium intervention arm and 156 were randomized to Healing Choices). The majority of the sample was non-Hispanic (272/282, 96%), White (239/314, 76%), married (251/320, 78.4%), and was on average 62.4 (SD 6.9) years old. Within both arms, there was a significant decrease in decisional conflict from baseline to 6 weeks postbaseline (Healium, P≤.001; Healing Choices, P≤.001), and a significant increase in satisfaction with one’s decision from 6 weeks to 3 months (Healium, P=.04; Healing Choices, P=.01). Within both arms, anxiety/tension (Healium, P=.23; Healing Choices, P=.27) and depression (Healium, P=.001; Healing Choices, P≤.001) decreased from baseline to 6 weeks, but only in the case of depression was the decrease statistically significant. ConclusionsHealium, our brief decision aid focusing on treatment preference elicitation, is as successful in reducing decisional conflict as our previously tested comprehensive decision aid, Healing Choices, and has the added benefit of brevity, making it the ideal tool for integration into the physician consultation and electronic medical record. Trial RegistrationClinicalTrials.gov NCT05800483; https://clinicaltrials.gov/study/NCT05800483

The objective of this study is to recover sludge from the Dar Gueddari sewage treatment plant and use it in the cultivation of corn in the open field on clay soil. To do this, four doses were tested against two types of controls: a control without addition of sludge and another with the addition of nitrogen-based fertilisers (200 kg N, 100 kg P and 100 kg K). The short-term effects indicated that the application of the sludge had a beneficial effect on the fertilising qualities of the soil and therefore on the crop yield. The monitoring of the agronomic parameters of the maize plant showed that the growths and the yields varied according to doses of the sludge. In grain yield, the difference between plot E4 and E0 was around 3.3 Mg∙ha –1. In addition, the plots treated with large sludge doses experienced improvements in total nitrogen and organic matter. During the second season, the results obtained showed decrease in nutrients (nitrogen and phosphorus). It emerged from the C:N ratio which was 8. This indicated a good mineralisation of the organic matter (OM) which was average of 2.48 ±0.04% and 2.5 ±0.01%, respectively in the E4 and E5 treatments. In addition, the amounts of N, P and Ca in dry matter (DM) increased with increasing the dose of sludge. During the 2017 season, the highest values were detected in plot E5 with averages of 1.6% in N and 0.53% in P.

Global climate change, exacerbated by greenhouse gas (GHG) emissions, notably carbon dioxide (CO2), provides a huge danger to lives, the global environment, and development. The current study explored the dynamic effects of economic growth, fossil fuel energy consumption, renewable energy consumption, tourism, and agricultural productivity on CO2 emissions in Egypt. The Dynamic Ordinary Least Squares (DOLS) method was used to analyze time series data from 1990 to 2019. The empirical findings revealed that, while economic growth, the use of fossil fuel energy, and tourism contribute to environmental damage by cumulative CO2 emissions in Egypt, an increased share of renewable energy and agricultural productivity contribute to improved environmental quality by lowering CO2 emissions. Similar results were obtained using alternative estimators such as fully modified least squares (FMOLS) and canonical cointegrating regression (CCR). Furthermore, the pairwise Granger causality test was used to determine the causal relationship between the variables. This study adds to the current literature by putting light on the causes of pollution in Egypt. This article made policy ideas for a low-carbon economy, boosting renewable energy consumption, green tourism, and climate-smart agriculture, all of which would assure environmental sustainability in Egypt by lowering emissions.

Objective To evaluate and quantify the indicators of fetal and maternal morbidity in deliveries for patients with systemic lupus erythematosus (SLE) compared with deliveries in patients without SLE.Methods We used retrospective data from the National Inpatient Sample (NIS) to identify all delivery related hospital admissions of patients with and without SLE from 2008 to 2017 using ICD-9/10 codes. Fetal morbidity indicators included pre-term delivery and intrauterine growth restriction (IUGR). 21 indicators of severe maternal morbidity were identified using standard Centers for Disease Control and Prevention (CDC) definitions. Descriptive statistics, including 95% confidence intervals, were calculated using sample weights from the NIS dataset.Results Among the 40 million delivery-related admissions, 51 161 patients were reported to have SLE. Patients with SLE had a higher risk of fetal morbidity, including IUGR (8.0% vs 2.7%) and pre-term delivery (14.5% vs 7.3%), than patients without SLE. During delivery, mothers with SLE were nearly four times as likely to require a blood transfusion or develop a cerebrovascular disorder, and 15 times as likely to develop acute renal failure than those without SLE.Conclusion Our study demonstrates that fetal morbidity and severe maternal morbidity occur at a higher rate in patients with SLE compared with those without. This quantitative work can help inform and counsel patients with SLE during pregnancy and planning.

Abstract Background Upcoming alternative payment models Primary Care First (PCF) and Kidney Care Choices (KCC) incorporate capitated payments for chronic disease management. Prior research on the effect of capitated payments on chronic disease management has shown mixed results. We assessed the patient, physician, and practice characteristics of practices with capitation as the majority of revenue, and evaluated the association of capitated reimbursement with quality of chronic disease care. Methods We performed a cross-sectional analysis of visits in the United States’ National Ambulatory Medical Care Survey (NAMCS) for patients with hypertension, diabetes, or chronic kidney disease (CKD). Our predictor was practice reimbursement type, classified as 1) majority capitation, 2) majority FFS, or 3) other reimbursement mix. Outcomes were quality indicators of hypertension control, diabetes control, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use, and statin use. Results About 9% of visits were to practices with majority capitation revenue. Capitated practices, compared with FFS and other practices, had lower visit frequency (3.7 vs. 5.2 vs. 5.2, p = 0.006), were more likely to be located in the West Census Region (55% vs. 18% vs. 17%, p

Background: Primary care physicians (PCPs) are often gatekeepers to specialist care. This study assessed the relationship between PCP density and total knee (TKA) and total hip arthroplasty (THA) outcomes. Methods: We obtained patient-level data from an institutional registry on patients undergoing elective primary TKA and THA for osteoarthritis, including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at baseline and 2 years. Using geocoding, we identified the number of PCPs in the patient’s census tract (communities). We used Augmented Inverse Probability Weighting and Cross-validated Targeted Minimum Loss-Based Estimation to compare provider density and outcomes adjusting for potential confounders. Results: Our sample included 3606 TKA and 4295 THA cases. The median number of PCPs in each community was similar for both procedures: TKA 2 (interquartile range 1, 6) and for THA 2 (interquartile range 1, 7). Baseline and 2-year follow-up WOMAC pain, function, and stiffness scores were not statistically significantly different comparing communities with more than median number of PCPs to those with less than median number of PCPs. In sensitivity analyses, adding 1 PCP to a community with zero PCPs would not have statistically significantly improved baseline or 2-year follow-up WOMAC pain, function, and stiffness scores. Conclusions: In this sample of patients who underwent elective TKA or THA for osteoarthritis, we found no statistically significant association between PCP density and pain, function, or stiffness outcomes at baseline or 2 years. Further studies should examine what other provider factors affect access and outcomes in THA and TKA.

Abstract Lifestyle interventions involving exercise training offset the adverse effects of androgen deprivation therapy in men with prostate cancer. Yet provision of integrated exercise pathways in cancer care is sparse. This study assessed the feasibility and acceptability of an embedded supervised exercise training intervention into standard prostate cancer care in a single-arm, multicentre prospective cohort study. Feasibility included recruitment, retention, adherence, fidelity and safety. Acceptability of behaviourally informed healthcare and exercise professional training was assessed qualitatively. Despite the imposition of lockdown for the COVID-19 pandemic, referral rates into and adherence to, the intervention was high. Of the 45 men eligible for participation, 79% (n = 36) received the intervention and 47% (n = 21) completed the intervention before a government mandated national lockdown was enforced in the United Kingdom. Patients completed a mean of 27 min of aerobic exercise per session (SD = 3.48), at 77% heart rate maximum (92% of target dose), and 3 sets of 10 reps of 3 resistance exercises twice weekly for 12 weeks, without serious adverse event. The intervention was delivered by 26 healthcare professionals and 16 exercise trainers with moderate to high fidelity, and the intervention was deemed highly acceptable to patients. The impact of societal changes due to the pandemic on the delivery of this face-to-face intervention remain uncertain but positive impacts of embedding exercise provision into prostate cancer care warrant long-term investigation.

Abstract Background The COVID-19 pandemic has forced many cancer services to consider a transition to a remote format of delivery that is largely untested. Accordingly, we sought to perform a systematic review of the effects of remotely delivered interventions to improve exercise behaviour in sedentary adults living with and beyond cancer. Methods Eligible studies were randomised controlled trials comparing a remotely delivered exercise intervention to a usual care comparison in sedentary people over 18 years old with a primary cancer diagnosis. Nine electronic databases were searched from inception to November 2020. Results The review included three trials, totalling 186 participants. Two of the included trials incorporated prescriptions that meet current aerobic exercise recommendations, one of which also meets the guidelines for resistance exercise. No trials reported an intervention adherence of 75% or more for a set prescription that meets current exercise guidelines. Conclusion There is little evidence suggesting that remote exercise interventions promote exercise behaviours or improve physical function in sedentary adults living with and beyond cancer. The development and evaluation of novel remote exercise interventions is needed to establish their usefulness for clinical practice. Given the social response to the COVID-19 pandemic, further research in this area is urgently needed.

Abstract Prescription opioid use (POU) is often a precursor to opioid use disorder (OUD) and subsequent consequences. Persons with chronic hepatitis C virus infection (CHC) may be at a higher risk of POU due to a higher comorbidity burden and social vulnerability factors. We sought to determine the burden of POU and associated risk factors among persons with CHC in the context of social vulnerability. We identified CHC persons and propensity-score matched HCV− controls in the electronically retrieved Cohort of HCV-Infected Veterans and determined the frequency of acute, episodic long-term and chronic long-term POU and the prevalence of social vulnerability factors among persons with POU. We used logistic regression analysis to determine factors associated with POU. Among 160,856 CHC and 160,856 propensity-score matched HCV-controls, acute POU was recorded in 38.4% and 38.0% (P = 0.01) respectively. Episodic long-term POU was recorded in 3.9% in each group (P = 0.5), while chronic long-term POU was recorded in 28.4% and 19.2% (P

تم في هذا البحث مناقشة التطور الباليوجغرافي الذي تعرضت له المنطقة الغربية من سوريا خلال الحقبين الثاني والثالث بشكل مختصر. وبيان انعكاس هذا التطور الباليوجغرافي وحركات النهوض التي تعرضت لها السلسلة الساحلية السورية على شكلها الحالي وتشكُّل الأودية النهرية بنوعيها التابعة والموافقة. وكيف قامت الأودية النهرية الموافقة بقطع مسار الأودية النهرية التابعة، مما تسبب في حدوث كثيرٍ من حوادث الأسر النهري، ولقد ترافق ذلك مع انتقال خطوط تقسيم المياه، وتغير مساحة الأحواض النهرية المتجاورة. مما أنعكس على تغذيتها المائية وعلى خصائصها الجيومورفولوجية والمورفومترية. ولقد تم في هذا البحث التركيز على دراسة حوادث الأسر النهري التي حصلت في القسم الأوسط من سلسلة الجبال الساحلية السورية، وذلك في رقعتي خرائط بانياس والقدموس والموضوعتين بمقياس . ولقد توصلنا نتيجة هذه الدراسة، التي تم تنفيذها لأول مرة، إلى تحديد مناطق حدوث الأسر النهري التي رافقت تشكل واديين تاليين رئيسيين في المنطقة المدروسة، هما وادي جهنم في حوض نهر جوبر. ووادي الجديدة – بورجيلة في حوض نهر الصرامطة. مع الإشارة إلى بعض المناطق الأخرى التي تم حدوث الأسر النهري فيها، أو يتوقع حدوثه أسر فيها مستقبلاً، والتي تتطلب مزيداً من الدراسة.

تناول هذا البحث دراسة وتحديد المداخن البركانية (volcanic necks) الموجودة في جنوب السلسلة الساحلية السورية، وذلك في رقع الخرائط (طرطوس، صافيتا، الحميدية، حلبا، والقسم الغربي من رقعتي تلكلخ، وقلعة الحصن)، مقياس . حيث تم إجراء دراسة حقلية وتوصيف للصخور البركانية التي تعود لعمر البليوسين في 78 موقعاً مفترضاً لوجود المداخن البركانية في منطقة الدراسة. وقد تبين من خلال هذه الدراسة وجود 17 مدخنة بركانية مؤكدة، وكذلك 9 مداخن يحتاج تأكيدها إلى مزيد من الدراسات، وهذه المداخن تتوزع في مواقع مختلفة من المنطقة المدروسة. وهذا أدى إلى استنتاج هام يؤكد بأن النشاط البركاني البليوسيني الذي حدث في جنوب المنطقة الانهدامية السورية لم يحدث فقط على الجانب الشرقي من الانهدام، كما أشارة إلى ذلك الدراسات السابقة، بل شمل مناطق متفرقة من الجانب الغربي أيضاً. كما أكدت هذه الدراسة أن الأقسام المتفرقة من الصبات البركانية التي تنتشر حالياً في أنحاء المنطقة المدروسة قد تشكلت نتيجة اندفاعات بركانية محلية المصدر، ولم يكن مصدرها فقط مركز البركنة الرئيسي الذي كان على الجانب الشرقي من الانهدام (هضبة شين).

A systematic review was conducted to identify the range of terminology used in studies to describe maximum walking distance and the exercise testing protocols, and testing modalities used to measure it in patients with intermittent claudication. A secondary aim was to assess the implementation and reporting of the exercise testing protocols. CINAHL, Medline, EMBASE and Cochrane CENTRAL databases were searched. Randomised controlled trials whereby patients with intermittent claudication were randomised to an exercise intervention were included. The terminology used to describe maximal walking distance was recorded, as was the modality and protocol used to measure it. The implementation and reporting quality was also assessed using pre-specified criteria. Sixty-four trials were included in this review. Maximal walking distance was reported using fourteen different terminologies. Twenty-two different treadmill protocols and three different corridor tests were employed to assess maximal walking distance. No single trial satisfied all the implementation and reporting criteria for an exercise testing protocol. Evidence shows that between-study interpretation is difficult given the heterogenous nature of the exercise testing protocols, test endpoints and terminology used to describe maximal walking distance. This is further compounded by poor test reporting and implementation across studies. Comprehensive guidelines need to be provided to enable a standardised approach to exercise testing in patients with intermittent claudication.

تناول هذا البحث دراسة وتحديد الخواص الجيومورفولوجية لنبع الغمقه الكارستي، وذلك باعتباره أحد الينابيع الموسمية التي تتدفق مياهها نحو الأعلى بشكل نافورة. ولهذا الغرض تم إجراء دراسة جيولوجية جيومورفولوجية تفصيلية في منطقة النبع. كما تم إجراء القياسات الحقلية اللازمة لرسم وتحديد الممر الكارستي الرئيسي الممتد تحت الأرض وتفرعاته، والذي يغذي هذا النبع بالمياه القادمة إليه من جهة الشمال الشرقي. وإيضاح التغيرات التي حصلت لمسار النبع، إضافة إلى إجراء مراقبة لتغيرات منسوب المياه داخل الممرات والتفرعات الكارستية، وربط ذلك مع فترات تدفق المياه عبر النافورة. أظهرت هذه الدراسة الأسباب التي أدت إلى تدفق مياه النبع وبغزارة شديدة عبر هذا الاتجاه. كما أوضحت العلاقة بين غزارة هذا النبع، وبين كميات الهطول المطري فوق منطقة التغذية. وقدمت شرحاً تفصيلياً لامتداد الممر الكارستي الذي يغذي هذا النبع بالمياه. وكذلك التطور الجيومورفولوجي الذي شهدته منطقة النبع خلال الأزمنة السابقة.

Objective There is emerging evidence that COVID-19 disproportionately affects people from racial/ethnic minority and low socioeconomic status (SES) groups. Many physicians across the globe are changing practice patterns in response to the COVID-19 pandemic. We sought to examine the practice changes among rheumatologists and what they perceive the impact to be on their most vulnerable patients.Methods We administered an online survey to a convenience sample of rheumatologists worldwide during the initial height of the pandemic (between 8 April and 4 May 2020) via social media and group emails. We surveyed rheumatologists about their opinions regarding patients from low SES and racial/ethnic minority groups in the context of the COVID-19 pandemic. Mainly, what their specific concerns were, including the challenges of medication access; and about specific social factors (health literacy, poverty, food insecurity, access to telehealth video) that may be complicating the management of rheumatologic conditions during this time.Results 548 rheumatologists responded from 64 countries and shared concerns of food insecurity, low health literacy, poverty and factors that preclude social distancing such as working and dense housing conditions among their patients. Although 82% of rheumatologists had switched to telehealth video, 17% of respondents estimated that about a quarter of their patients did not have access to telehealth video, especially those from below the poverty line. The majority of respondents believed these vulnerable patients, from racial/ethnic minorities and from low SES groups, would do worse, in terms of morbidity and mortality, during the pandemic.Conclusion In this sample of rheumatologists from 64 countries, there is a clear shift in practice to telehealth video consultations and widespread concern for socially and economically vulnerable patients with rheumatic disease.

Objectives This study aimed to characterise the exercise performed in UK cardiac rehabilitation (CR) and explore relationships between exercise dose and changes in physiological variables.Design Observational cohort study.Setting Outpatient community-based CR in Leeds, UK. Rehabilitation sessions were provided twice per week for 6 weeks.Participants Sixty patients (45 male/15 female 33–86 years) were recruited following referral to local outpatient CR.Outcome measures The primary outcome was heart rate achieved during exercise sessions. Secondary outcomes were measured before and after CR and included incremental shuttle walk test (ISWT) distance and speed, blood pressure, brachial artery flow-mediated dilatation, carotid arterial stiffness and accelerometer-derived habitual physical activity behaviours.Results The mean % of heart rate reserve patients exercised at was low and variable at the start of CR (42%±16 %) and did not progress by the middle (48%±17 %) or end (48%±16 %) of the programme. ISWT performance increased following CR (440±150 m vs 633±217 m, p0.05).Conclusion Patients in a UK CR cohort exercise at intensities that are variable but generally low. The exercise dose achieved using this CR format appears inadequate to impact markers of health. Attending CR had no effect on physical activity behaviours. Strategies to increase the dose of exercise patients achieve during CR and influence habitual physical activity behaviours may enhance the effectiveness of UK CR.

Introduction The first-line recommended treatment for patients with intermittent claudication (IC) is a supervised exercise programme (SEP), which includes a minimum of 2-hours of exercise per week over a 12-week period. However, provision, uptake and adherence rates for these SEP programmes are poor, with time constraints cited as a common participant barrier. High-intensity interval training (HIIT) is more time-efficient and therefore has the potential to overcome this barrier. However, evidence is lacking for the role of HIIT in those with IC. This proof-of-concept study aims to consider the safety, feasibility, tolerability and acceptability of a HIIT programme for patients with IC.Methods and analysis This multicentre, single-group, prospective, interventional feasibility study will recruit 40 patients with IC, who will complete 6 weeks of HIIT, 3 times a week. HIIT will involve a supervised programme of 10×1 min high-intensity cycling intervals at 85%–90% peak power output (PPO), interspaced with 10×1 min low intensity intervals at 20%–25% PPO. PPO will be determined from a baseline cardiopulmonary exercise test (CPET) and it is intended that patients will achieve ≥85% of maximum heart rate from CPET, by the end of the second HIIT interval. Primary outcome measures are safety (occurrence of adverse events directly related to the study), programme feasibility (including participant eligibility, recruitment and completion rates) and HIIT tolerability (ability to achieve and maintain the required intensity). Secondary outcomes include patient acceptability, walking distance, CPET cardiorespiratory fitness measures and quality of life outcomes.Ethics and dissemination Ethical approval was obtained via a local National Health Service research ethics committee (Bradford Leeds – 18/YH/0112) and recruitment began in August 2019 and will be completed in October 2020. Results will be published in peer-reviewed journals and presented at international conferences and are expected to inform a future pilot randomised controlled trial of HIIT versus usual-care SEPs.Trial registration number NCT04042311; Pre-results.

Artesunate is the current most potent antimalarial drug widely used for the treatment of malaria. Considering the emergence of artemisinin resistance, several situations may require a simple method for artesunate quantification. We thus developed a quantitative and a semi-quantitative biological method for the determination of artesunate in liquid samples. The tests are based on the measurement of samples’ antimalarial activity on Plasmodium falciparum 3D7 using a modified SYBR Green I drug susceptibility test. For the quantitative test, we established a standard curve that resulted from a dose–response curve and evaluated its performances using controls samples. Whereas the linear regression analysis between artesunate concentration and antimalarial activity showed promising results (linearity range 1.5–24.6 ng/mL, r2 = 0.9373), we found that artesunate content of the controls was significantly overestimated (p = 0.0313). For the semi-quantitative test, we compared the antimalarial activities of samples collected during permeation studies of artesunate to that of a reference (artesunate IC50) by statistical analysis. We demonstrated that antimalarial activities of samples from permeation tests using a powder formulation of artesunate were greater than those of samples from tests using a solution formulation. Bioassays can be simple techniques to assess artesunate in liquid samples, particularly in resource-limited settings. Comparison with reference methods is still recommended when accurate drug quantification is required.

Background Most humerus shaft fractures can be treated successfully using the conservative methods. When choosing surgical fixation, there is a debate between the use of plate and screws and intramedullary nails. Aims The aim of this study was to compare the results of the dynamic compression plate and the antegrade interlocked humeral nail in the fixation of humerus shaft fractures. Patients and methods A total of 40 patients were selected by a randomized method to be treated by either method; there were 20 patients in each group and patients were followed up for at least 6 months until union. Result The results showed superiority of the plate in terms of the union rate and shoulder function and the use of the nail was better in terms of the infection rate and radial nerve palsy. Conclusion The plate is still the standard of treatment of the humerus shaft fracture and the nails better be used for more comminuted or open fractures. More future studies with large numbers required to overcome our relatively small number.

OBJECTIVES/GOALS: While there are many well-documented factors for racial/ethnic variation in discharge destination, less is known about the role hospital processes play. We hypothesize that variation in hospital processes -defined as the patient length of stay (LOS) adjusted for known confounders - explains racial/ethnic variation in discharge destination. METHODS/STUDY POPULATION: Our sample was 176,686 discharges from 165 hospitals in 2014 using the New York State Inpatient Dataset from the Healthcare Cost and Utilization Project, merged with the 2014 American Hospital Association Annual Survey to build a file of inpatient discharges with patient, disease and socio-economic characteristics. We excluded patients under 18 years, those with LOS of zero, those who died, those admitted to critical access hospitals, and patients from hospitals that lacked sufficient number of minority patients. We used a generalized linear mixed effects model to create an in-hospital risk-adjusted LOS by modelling the relationship between the interaction of race and discharge destination and LOS, controlling for known confounders such as patient, disease and between-hospital characteristics. RESULTS/ANTICIPATED RESULTS: Mean age of sample was 56.5 years, 57.3 % female, 54.9% white, 18.9% black and 13.1% Hispanic; 64.3% were discharged home, 15.8% to a skilled nursing or other intermediate care facility, 15.5% to home with home care and 2.4% left against medical advice. The top 3 discharge diagnoses were vaginal delivery (6.3% of discharges), psychosis (4.7%), and major joint replacement (2.9%). In adjusted analysis compared to white patients, black and Hispanic patients did not have an risk of increased LOS after being discharged to non-home destinations vs. discharged home, (black patients, adjusted OR [AOR], 0.97; 95% CI: 0.94-1.00, p = 0.08; Hispanic patients, AOR, 1.01; 95% CI: 0.98 – 1.05, p = 0.5). However, being black compared to white and discharge to non-home destinations significantly increased LOS. DISCUSSION/SIGNIFICANCE OF IMPACT: In this large sample of patients admitted for inpatient care in 2014 in New York, we found no independent effect between race and discharge destination on a patient’s LOS after controlling for patient, disease and between-hospital characteristics. However race/ethnicity increased LOS, suggesting its effect may play a role on in-hospital processes CONFLICT OF INTEREST DESCRIPTION: Dr. Ghosh has no relevant relationships with commercial interests to disclose Dr. Ibrahim has no relevant relationships with commercial interests to disclose

ABSTRACT IMPACT: Patients living in overcrowded zip codes were at increased risk of contracting severe COVID-19 after controlling for confounding disease and socioeconomic factors OBJECTIVES/GOALS: This study sought to examine whether residences in over-crowded zip codes with higher reported over-crowding represented an independent risk factor for severe COVID-19 infection, defined by presentation to an emergency department. METHODS/STUDY POPULATION: In this zip code tabulated area (ZCTA)-level analysis, we used NYC Department of Health disease surveillance data in March 2020 merged with data from the CDC and ACS to model suspected COVID-19 case rates by zip code over-crowdedness (households with greater than 1 occupant per room, in quartiles). We defined suspected COVID-19 cases as emergency department reported cases of pneumonia and influenza-like illness. Our final model employed a multivariate Poisson regression models with controls for known COVID-19 clinical (prevalence of obesity, coronary artery disease, and smoking) and related socioeconomic risk factors (percentage below federal poverty line, median income by zip-code, percentage White, and proportion of multigenerational households) after accounting for multicollinearity. RESULTS/ANTICIPATED RESULTS: Our analysis examined 39,923 suspected COVID-19 cases across 173 ZCTAs in NYC between March 1 and March 30 2020. We found that, after adjusted analysis, for every quartile increase in defined over-crowdedness, case rates increased by 32.8% (95% CI: 22.7%% to 34.0%, P < 0.001). DISCUSSION/SIGNIFICANCE OF FINDINGS: Over-crowdedness by zip code may be an independent risk factor for severe COVID-19. Social distancing measures such as school closures that increase house-bound populations may inadvertently worsen the risk of COVID-19 contraction in this setting.

Background: Total knee arthroplasty (TKA) provides good clinical outcomes for the treatment of end-stage osteoarthritis; however, discharge destination after TKA has major implications on postoperative adverse outcomes and readmissions. With the initiation of Bundled Payments for Care Improvement (BPCI), it is unclear how racial disparities in discharge destination after TKA will be affected by the new bundled payment for TKA. Methods: Bundled Payments for Care Improvement was implemented in July 01, 2014, at the University of Pennsylvania. We compared differences during early implementation (July 1, 2014, to, March 30, 2016) and during late policy implementation (April 1, 2016, to February 28, 2017) in patient characteristics (including race: African American [AA], white, and other race), discharge destination (skilled nursing facility [SNF], inpatient rehabilitation facility, home, home with home health, or other), and outcomes. Results: We identified 2276 patients who underwent TKA (43.8% AA, 48.2% white, and 8.0% other race). African American patients were more likely to be discharged to SNF as opposed to home than white patients both during the early BPCI (AA: 53.0%, n = 320; white: 32.4%, n = 210, P < .05) and late BPCI implementation (AA: 44.4%, n = 169, white: 26.9%, n = 120, P < .05), though all races showed trends to decreasing SNF use during the late BPCI implementation. Discussion: There were no significant differences in readmissions, length of stay, mortality, or intensive care unit days during early and late implementation of BPCI or when AA patients were compared to white patients. Conclusion: We found no significant changes in racial variations in discharge destination and outcomes after elective TKA. Bundled Payments for Care Improvement has encouraged better preoperative preparation of patients and discharge planning; however, payment reforms alone might not be sufficient to address variation in post-op management following elective surgery.

This research define and study geomorphological properties of the Karstic Polje, located in the southern parts of the coastal area “Beerat Aljerd and Ein alshams rgeons” For this issue, we have used “ G I S” Technology to clarify properties and place of this Polje through construction few of informatics slides that contain different types of data, showing Karstic Polje limits, dimensions, topography of the region, and situated Karstic characteristics Blind valleys, sink holes, solution doline, hums. Following, we have studied the Paleogeogeaphic development of the study area, in addition to the forming conditions, and Geomorphological periods related with this region. Finally, This study showed the great hydrology importance, resulted from presence of this Karstic Polje in the mentioned region, through infiltration of large quantities of rain water by precipitation with annual average up to 1475 m m. This water moves often through water bearing formations toward the west, where flow out of the Polje and contribute in consisting of water storage for the coastal area.

Parainfluenza virus (PIV) causes respiratory infections with high rates of morbidity and mortality in Children and immune-deficiency patients worldwide. The aim of this study is to detect the changes of mRNA expression of 84 human inflammatory genes and gene ontology analysis. From 90 patients only 2 gave positive IgM –PIV test. PIV infection caused over expression of 25 prominent genes (from 168 genes) affect functional pathways, ten of these genes regard as proinflammatory genes. Three genes were down-regulated; this suggests that the host-viral interaction is a cellular response against viral infection. In conclusion: Gene ontology analysis revealed that PIV stimulated 4 different key role immunological pathways represented by cytokine-cytokine receptor interaction, NOD-like receptor signaling, Toll-like receptor signaling, and asthma pathway. The patients are mostly infected with related subtypes of PIV. These results may help in further analysis of viral-host interaction.

This research deals with the issue of séance, which has spread amongst educated people as well as uneducated ones in our Arab and Islamic societies. The issue belongs to the realm of the unseen. Such an alien issue represents significant aberration from our religious and ethical norms, ideals and behaviour. Related aberrations include sorcery, hypnotism and alleged knowledge of the future. They contradict our fundamental Islamic beliefs. Therefore, it becomes imperative for Islamic investigation to scrutinize the broader issue of spiritism in order to indentify its fallacies and inconsistencies with reality as well as its negative impact on our Arab and Islamic societies.

Objectives: To determine whether workplace conditions affect care quality and errors, especially in primary care clinics serving minority patients. Methods: We conducted a 3-year assessment of work conditions and patient outcomes in 73 primary care clinics in the upper Midwest and New York City. Study participants included 287 physicians and 1204 patients with hypertension and/or diabetes. Chart audit data were contrasted between clinics with ≥30% minority patients (minority-serving clinics, or MSCs) and those with

Background:The study was targeted to report the appearance of coproantigens in feces and circulating antibodies in the serum of Fasciola gigantica experimentally infected rabbits. Methods: Copro Hyper Immune Serum (HIS) and Excretory-Secretory Hyper Immune Serum (ES HIS) antigens were used in a sandwich ELISA for the detection of F. gigantica antigens in feces of 12 rabbits experimentally infected with different doses of F. gigantica encysted metacercariae (EMC) (10, 25 and 30 EMC). The relation between time of appearance of coproantigens in feces and anti-Fasciola antibodies in serum was evaluated. Results: The earliest diagnostic coproantigen was recorded at 21st, 25th and 28th day post-infection (p.i.) in groups of rabbits infected with 30, 25 and 10 F. gigantica EMC respectively. Both HIS and ES HIS were able to detect coproantigens in feces of rabbits infected with 30 EMC at day 21 p.i. The appearance of F. gigantica coproantigens in feces of infected rabbits was concurrent to the appearance of anti-Fasciola antibodies in blood (3rd week p.i.).However, coproantigen has specific ability for direct assessment of active infection with minimal cross-reaction with other heterologous parasitic infections. Conclusion: The findings hold promise for a more accurate diagnostic technique in the near future for suspected Fasciola infection.

Introduction: Spindle cell oncocytoma of the adenohypophysis is a rare tumour recently reported by Roncaroli et al. in 2002. This tumour is considered a grade I tumour by the World Health Organization., Case Presentation: We describe what is, to the best of our knowledge, the 14th case of its kind in the literature. A 45-year-old African woman presented clinical and radiological findings related to a nonfunctioning pituitary adenoma. The diagnosis was made on the basis of histological and immunohistochemical findings., Conclusion: The purpose of this work is to report a rare pituitary tumour and to describe its histological and immunohistochemical features, which were characterized by the expression of thyroid transcription factor 1 antigen by tumour cells. This fact could support the theory of a possible common origin of these tumours in pituicytomas. In fact, thyroid transcription factor 1 is considered to be a specific marker of pituicytes.