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Hayat Mushcab,1 Jaffar A Al-Tawfiq,2– 4 Amani Babgi,5 Mohammed Ghamdi,6 Abdulrazack Amir,7 Salwa S Sheikh,8 Adel Darwisheh,9 Abrar AlObaid,9 Emad Masuadi,10 Areej AlFattani,11 Saeed Qahtani,12 Ahmed Al Sagheir1 1Research Office, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; 2Specialty Internal Medicine and Quality and Patient Safety Departments, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; 3Infectious Disease Division, Department of Medicine, Indiana University School of Medicine, IN, Indiana, USA; 4Infectious Disease Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 5Nursing Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; 6Population Health Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; 7Office of Academic Affairs, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; 8Pathology Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; 9Laboratory Services Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; 10Medical Education Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 11Biostatistics and Epidemiology Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; 12Wellness Institute, Johns Hopkins Aramco Healthcare, Dhahran, Saudi ArabiaCorrespondence: Hayat Mushcab, Research Office, Johns Hopkins Aramco Healthcare, Dhahran, 31311, Saudi Arabia, Email hayat.almushcab@jhah.comBackground: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused the latest pandemic and the most significant challenge in public health worldwide. Studying the longevity of naturally developed antibodies is highly important clinically and epidemiologically. This paper assesses the longevity of antibodies developed against nucleocapsid protein amongst our health-care workers.Methods: This longitudinal cohort study was conducted at a tertiary hospital, Saudi Arabia. Anti-SARSsCoV-2 antibodies were tested among health-care workers at three-point intervals (baseline, eight weeks, and 16 weeks).Results: Of the 648 participants, 112 (17.2%) tested positive for Coronavirus (COVID-19) by PCR before the study. Of all participants, 87 (13.4%) tested positive for anti-SARS-CoV-2 antibodies, including 17 (2.6%) participants who never tested positive for COVID-19 using rt-PCR. Out of the 87 positive IgG participants at baseline, only 12 (13.7%) had remained positive for anti-SARS-CoV-2 antibodies by the end of the study. The IgG titer showed a significant reduction in values over time, where the median time for the confirmed positive rt-PCR subgroup from infection to the last positive antibody test was 70 (95% CI: 33.4– 106.5) days.Conclusion: Health-care workers are at high risk of exposure to the SARS-CoV-2 virus, and contracting an asymptomatic infection is not unlikely. Developing and sustaining natural immunity differs from one person to another, while the rate of positive IgG anti-SARS-CoV-2 wanes over time.Clinicaltrials.gov Identifier: NCT04469647, July 14, 2020.Keywords: antibodies, longevity, COVID-19, SARS-CoV-2, healthcare workers, HCW

Hayat Mushcab,1 Jaffar A Al-Tawfiq,2– 4 Mohammed Ghamdi,5 Amani Babgi,6 Abdulrazack Amir,7 Salwa S Sheikh,8 Adel Darwisheh,9 Abrar Alobaid,9 Arulanantham Zechariah Jebakumar,10 Saeed Qahtani,11 Ahmed Al Sagheir1 1Research Office, Johns Hopkins Aramco Healthcare, Dhahran, Eastern Province, Saudi Arabia; 2Infectious Disease Unit – Specialty Internal Medicine, and Quality and Patient Safety Department, Johns Hopkins Aramco Healthcare, Dhahran, Eastern Province, Saudi Arabia; 3Infectious Disease Division, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; 4Infectious Disease Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 5Population Health Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; 6Clinical Practice Education & Research, Johns Hopkins Aramco Healthcare, Dhahran, Eastern Province, Saudi Arabia; 7Office of Academic Affairs, Johns Hopkins Aramco Healthcare, Dhahran, Eastern Province, Saudi Arabia; 8Pathology Department, Johns Hopkins Aramco Healthcare, Dhahran, Eastern Province, Saudi Arabia; 9Laboratory Services Department, Johns Hopkins Aramco Healthcare, Dhahran, Eastern Province, Saudi Arabia; 10Vice Deanship of Postgraduate Studies Research, Prince Sultan Military College of Health Sciences, Dhahran, Eastern Province, Saudi Arabia; 11Wellness Institute, Johns Hopkins Aramco Healthcare, Dhahran, Eastern Province, Saudi ArabiaCorrespondence: Hayat Mushcab, Research Office, Johns Hopkins Aramco Healthcare, Dhahran, 31311, Eastern Province, Saudi Arabia, Tel +966540066447, Email hayat.almushcab@jhah.comBackground: The nature of the healthcare workers’ jobs standing at the frontline against the coronavirus disease 2019 (COVID-19) puts them at a higher risk of unknowingly contracting the disease and potentially contributing to the spread. This study aims to assess the overall positive seroconversion prevalence of SARS-CoV-2.Methods: This is a longitudinal cohort study of healthcare workers at Johns Hopkins Aramco Healthcare (JHAH). JHAH is a tertiary hospital located in Dhahran serving patients in several districts in the Eastern Province of Saudi Arabia. Participants were recruited between June and December 2020. Each participant had a serology blood test and completed the World Health Organization’s risk factor assessment questionnaire.Results: This study included 682 participants working in JHAH, representing 15.7% of our population. Out of the 682 participants, 15.2% had a positive SARS-CoV-2 rt-PCR before taking part in the study. However, only 87 tested positive for SARS-CoV-2 antibodies, a prevalence of 12.7% of all participants. Out of the 87 positives for SARS-CoV-2 antibodies, 17 participants never tested positive for COVID-19 rt-PCR, a prevalence of 2.9%. Moreover, not properly using alcohol-based hand rub or soap and water after the risk of body fluid exposure and wearing personal protective equipment when indicated were found to be statistically significant to having a positive SARS-CoV-2 IgG assay.Conclusion: Positive seroconversion rate was considerably low during the first wave of COVID-19 amongst JHAH’s healthcare workers and similar to other healthcare organizations in Saudi Arabia. Seropositivity correlated significantly with following infection prevention and control recommendations.Clinicaltrials.gov Identifier: NCT04469647.Keywords: COVID-19, coronavirus disease-2019, HCW, healthcare workers, prevalence, SARS-CoV-2

Every year, pulmonary embolism (PE) causes about 100,000 fatalities in the United States. Acute PE is a prevalent and occasionally fatal kind of venous thromboembolism (VTE). PE can appear in a variety of ways and is frequently nonspecific in its clinical presentation, making its diagnosis challenging. In order to limit the associated morbidity and mortality, individuals with suspected PE should be evaluated efficiently. This will allow for a prompt diagnosis and administration of medication. An efficient and convenient method for diagnosing PE is to use an electrocardiogram (EKG). Remembering that the typical EKG for PE cannot always be present is essential. Sinus tachycardia, a fairly nonspecific EKG presentation, is the most common. In this case report, we present a 60-year-old male who exhibited signs and symptoms of chest pain and dyspnea, with EKG showing atrial flutter, and was ultimately diagnosed with PE as the underlying trigger. The objective of this case study presentation was to highlight the need to rule out PE in patients exhibiting dyspnea and chest pain, even in the absence of a traditional textbook EKG appearance. It is very crucial to consider the holistic presentation of the patient. Acute onset dyspnea and chest pain should always prompt PE as an important differential., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Saha et al.)

This paper introduces a robust method for estimating states and switching signals in impulsive switched systems with unknown inputs. It uses a reduced-order estimator to handle inaccessible states and an output derivative-based method to address the effects of unknown inputs, even though this adds some impulsive effects. The method is divided into two main steps: first, dedicated estimators determine the switching signal and identify the active subsystem; then, state estimation is carried out. By incorporating the estimated switching signal, the method effectively eliminates impulsive effects caused by unknown inputs. The study also explores the key conditions needed to ensure that estimation errors decrease exponentially. It uses a common Lyapunov function and Linear Matrix Inequality techniques. Simulation results show that this method is both efficient and effective, outperforming single-estimator approaches., 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 © 2024 ISA. Published by Elsevier Ltd. All rights reserved.)

Alluvial fans and deltas are two environments with different hydrochemical conditions. Their junction zones, as mixing environments, are variably influenced by different processes, leading to variable environmental conditions. The purpose of this study is to investigate groundwater quality in the junction zone of these environments in the northern part of the Jazmourian depression (known as the Rudbar plain) in southeastern Iran to determine the dominant processes, assess arsenic and fluoride health risks, and evaluate irrigation water quality. A total of 33 samples from deep drilled wells were taken, and the concentrations of major ions and elements were determined. Additionally, statistical and hydrochemical analyses were undertaken. The dominant processes in the delta are evaporation and ion exchange, while the dominant process in the fan environment is silicate hydrolysis. Among the samples, 26.7% were mainly affected by the delta, and 73.3% were mainly affected by fan conditions. Although the majority of groundwater samples were suitable for irrigation based on quality standards, a significant portion exceeded the acceptable level for Na%. Non-carcinogenic health risk assessments indicated that arsenic hazard risks exceeded thresholds in 63.3% of cases for children and 36% for adults. Carcinogenic health risks associated with arsenic and fluoride exceeded acceptable levels in 4 and 2 stations, respectively. Elevated As concentrations contribute to a greater average health risk in parts of fans environment., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Bilateral tubal ectopic pregnancy (BTP) is a rare and potentially life-threatening condition that is, often challenging to diagnose preoperatively., Presentation of Case: We present a case of BTP in a 25-year-old primigravid woman with a history of infertility due to polycystic ovarian syndrome. She was receiving letrozole when she presented with severe abdominal pain and vaginal bleeding. Initial evaluation revealed a ruptured ectopic pregnancy in the right fallopian tube, prompting an emergency laparotomy. During surgery, a second intact ectopic mass was discovered in the left fallopian tube, highlighting the diagnostic complexity of BTP. Management involved a salpingectomy on the right side and salpingostomy on the left to preserve fertility., Discussion: This case underscores the importance of considering BTP in the differential diagnosis of ectopic pregnancies and the necessity for thorough preoperative imaging studies, namely ultrasonography and surgical exploration, to prevent missed diagnoses., Conclusion: BTP is a rare and challenging clinical entity that requires a comprehensive approach to diagnosis and management. Early recognition, prompt intervention, and close surveillance are essential to mitigate the risk of maternal morbidity and mortality associated with this condition., Competing Interests: Conflict of interest statement All authors declare that there is no conflict of interest to disclose., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: This study was undertaken to evaluate the role of regional social vulnerability in geographic disparity for patients listed for liver transplantation with non-hepatocellular carcinoma (HCC) model for end-stage liver disease (MELD) exceptions., Summary and Background: Prior work has demonstrated regional variability in the appropriateness of MELD exceptions for diagnoses other than HCC., Methods: Adults listed at a single center for first-time liver-only transplantation without HCC after June 18, 2013 in the Scientific Registry of Transplant Recipients database as of March 2021 were examined. Candidates were mapped to hospital referral regions (HRRs). Adjusted likelihood of mortality and liver transplantation were modeled. Advantaged HRRs were defined as those where exception patients were more likely to be transplanted, yet no more likely to die in adjusted analysis. The Centers for Disease Control's Social Vulnerability Index (SVI) was used as the measure for community health. Higher SVIs indicate poorer community health., Results: There were 49,494 candidates in the cohort, of whom 4337 (8.8%) had MELD exceptions. Among continental US HRRs, 27.3% (n = 78) were identified as advantaged. The mean SVI of advantaged HRRs was 0.42 versus 0.53 in nonadvantaged HRRs ( P = 0.002), indicating better community health in these areas. Only 25.3% of advantaged HRRs were in spatial clusters of high SVI versus 40.7% of nonadvantaged HRRs, whereas 44.6% of advantaged HRRs were in spatial clusters of low SVI versus 38.0% of nonadvantaged HRRs ( P = 0.037)., Conclusions: An advantage for non-HCC MELD exception patients is associated with lower social vulnerability on a population level. These findings suggest assigning similar waitlist priority to all non-HCC exception candidates without considering geographic differences in social determinants of health may actually exacerbate rather than ameliorate disparity., Competing Interests: R.M.C. is supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award number K08DK125769. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Oral health is linked to physical and mental well-being. Oral disease is common among poor and socioeconomically disadvantaged people in developing and industrialized countries ., Objectives: This study assessed the oral health disease burden among people with multimorbidity in marginalized populations., Methods: This cross-sectional study was conducted across 16 locations in the slums of Karachi, Pakistan, to assess oral health disease problems among adults aged 18 to 70 with comorbidity or multimorbidity. The questionnaire covered the socioethnic, demographic, and disease status of people with oral health status. Data analyses were performed using SAS version 9.4., Results: Of the 16 designated slum locations, 870 individuals were considered for oral health screening. Gingivitis was highly prevalent, 29% among slum dwellers with multimorbidity of diabetes, hepatitis, and hypertension. Dandasa was widely used as a tooth-cleansing agent in 35% of the study population. By contrast, 45.4% of people showed unsatisfactory oral hygiene conditions. Pathan ethnicity showed the highest prevalence (i.e., 29.8% of dental problems with disease multimorbidity in 26.8% of Baldia Town residents of Karachi). Of the 870 individuals, the highest frequency of dental problems was found in the age group of 18-38 years (28-42.9%) and among female participants (53.8%)., Conclusion: There is an urgent need for the global enhancement of public health programs, specifically focusing on implementing effective strategies to prevent oral illnesses, promote oral health, and address other chronic diseases in basic healthcare settings. Enhancing oral health poses significant difficulties, especially in less developed nations., (© 2024 The Authors.)

Insulin resistance complicates diabetes care. Its effectiveness and tolerability as an addition to metformin, DPP4 inhibitor and insulin treatment in type 2 diabetic patients will be examined in this research. Participants with type 2 diabetes from poor socio-economic backgrounds had HbA1c values ≥8.5% when using Insulin+Metformin+DPP-4 inhibitors. They received 10mg Empagliflozin daily for 12 weeks (n=143). The main outcome was change in HbA1c at 12 th week from baseline. Secondary outcomes were baseline weight and week 12 FPG. Adjusted mean (SE) HbA1c increases at week 12 were: Mean ± SD 10.38 (6.8-17.0) vs. Mean±SD 9.05±1.77 (5.60-16.0) with empagliflozin 10mg. When added to the regimen, empagliflozin significantly reduced FPG, systolic and diastolic blood pressure. The mean (SE) BMI increases from baseline were 31.28±5.89 (16.0-66.0) and 29.73±5.47 (3.0-46.0) with 10mg empagliflozin. Two individuals experienced urinary tract infections as AEs, but no genital infections. Adding empagliflozin 10mg daily to metformin+DPP4 inhibitor+insulin improved glycemic control, body weight and blood pressure for 12 weeks. The intervention was well-tolerated, highlighting empagliflozin's therapeutic potential.

Background: Metabolic syndrome (MetS) is a cluster of cardiometabolic risk factors which increase the likelihood of developing type 2 diabetes and cardiovascular disease. This study aimed to determine the prevalence of MetS among adolescents living in slums aged 11-18 years in Karachi, Pakistan., Methods: Data were collected from 689 adolescents attending five schools in two slum areas of Karachi, Korangi and Baldia, from February 2023 to March 2023. Measurements of weight, height, waist circumference, and blood pressure were obtained from the study participants. Blood samples were collected to assess fasting plasma glucose, High density lipoprotein HDL-cholesterol, and triglyceride levels as per National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III). The prevalence of MetS was estimated using five diagnostic criteria, i.e., International Diabetes Federation (IDF-2007), World Health Organization, NCEP-ATP III, de Ferranti et al., and Cruz and Goran., Findings: The study revealed an overall prevalence of MetS among the adolescents in the two slum areas as 16.7%. A higher prevalence of MetS was observed among females (9.1%) and those with lower body mass index BMI (13.6%). The diagnostic criteria proposed by Cruz and Goran were found to be the most sensitive, with a MetS diagnosis rate of 22.93%. The study also identified several significant risk factors associated with MetS, including sedentary lifestyle (7.7%), lack of physical activity (7.5%), increased screen time (1.5%), lower fruit consumption (6.1%), and underweight (7.7%). Among slum-dwelling adolescents, low levels of HDL-cholesterol (33.96 ± 5.21), high triglyceride levels (161.45 ± 63.09), and elevated fasting plasma glucose levels (112.59 ± 28.92) were prevalent components of MetS., Interpretation: This study provides compelling evidence of a high prevalence of MetS among marginalised school-going adolescents in Karachi, Pakistan. The findings underscore the importance of early identification of adolescents at risk of developing MetS (especially those living in slum areas) and the implementation of effective preventive strategies to mitigate the risk of type 2 diabetes and cardiovascular disease in later life., Funding: None., Competing Interests: The authors state that the study was conducted without commercial or financial ties, which may be seen as a potential conflict of interest., (© 2024 The Author(s).)

Dietary nitrates (NO3-) are naturally occurring compounds in various vegetables, especially beetroot, which is mainly supplemented in the form of BRJ. Dietary nitrates (NO3-) play a crucial function in human physiology. On consumption, nitrates (NO3-) undergo a conversion process, producing nitric oxide (NO) via a complex metabolic pathway. Nitric oxide (NO) is associated with many physiological processes, entailing immune modulation, neurotransmission, and vasodilation, enabling blood vessel dilation and relaxation, which boosts blood flow and oxygen delivery to tissues, positively influencing cardiovascular health, exercise performance, and cognitive function. There are various analytical processes to determine the level of nitrate (NO3-) present in dietary sources. The impact of dietary nitrates (NO3-) can differ among individuals. Thus, the review revisits the dietary source of nitrates (NO3-), its metabolism, absorption, excretion, analytical techniques to assess nitrates (NO3-) content in various dietary sources, and discusses health effects., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Anxiety and depression often exacerbate multimorbidity conditions, leading to increased disability rates among affected individuals., Objective: The study aimed to assess the mental health status of individuals with multimorbidity belonging to the marginalized population of Karachi, Pakistan. Specifically, the prevalence of anxiety and depression was investigated., Methods: A multicenter cross-sectional study was conducted between July 2022 and June 2023 in 10 primary healthcare clinics located in 4 peri-urban areas of Karachi. A total of 9331 participants were included in the study. The Patient Health Questionnaire 4 (PHQ-4), Generalized Anxiety Disorder 7 (GAD-7), and Patient Health Questionnaire 9 (PHQ-9) were used to assess symptoms of anxiety and depression. The data collected were analyzed using the statistical analysis system (SAS) version 9.4., Results: Among the study participants, 2894 (31%) were men and 5534 (59.3%) were women. The prevalence of moderate to severe anxiety was 31% among men and 59.3% among women. The age group between 41 and 60 years exhibited the highest rates of moderate to severe anxiety, 19.3% as evaluated by GAD-7 and 34.6% by PHQ-9. The Pathan ethnic group had the highest prevalence of anxiety (11%) and depression (28.3%) in the neighborhoods. Unemployed participants showed moderate to severe anxiety in 21.3% of the cases and moderate to severe depression in 25.5% of the cases., Conclusion: The study revealed a significant cooccurrence of anxiety and depression among individuals with multimorbidity in the marginalized population of Karachi, Pakistan. Furthermore, the presence of anxiety symptoms in multimorbidity patients with depression indicates a more unfavorable health state. It is essential to explore the implementation of screening measures and therapeutic interventions for comorbid anxiety and depression in this population to improve clinical outcomes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Aging and gender are risk factors for urine incontinence, which can lead to psychological, physical, and social complications., Objective: This community-based study investigates the effectiveness of pelvic floor muscle training on the severity and quality of urine incontinence and social participation of older women., Methods: This quasi-experimental community-based study was performed with the participation of 60 older women referring to the Public Health Center in Kerman City, southern Iran. The experiment group was trained with pelvic floor muscle training in 7 training sessions with distance health education in the second half of 2021. Before and after the intervention, data were collected based on: demographic, severity and quality of urine incontinence, and social participation inventories. Data were analyzed using a t-test and ANOVA (P ≤ 0.05)., Results: The mean scores of severity and quality of urine incontinence and social participation in the experiment and control groups before receiving the intervention were not statistically significant (P ≥ 0.05). But after that, a statistically significant difference was observed between the groups (P <0.05), which showed an improvement in the severity and quality of urine incontinence scores as well as SP in the experiment group., Conclusions: Tele-training of the Kegel exercise, even during the pandemic, can play an important role in improving incontinence and social participation in older women. Therefore, this training can be used to prevent and improve urine incontinence in public health centers in the community.

Introduction: Liver allocation changes have led to increased travel and expenditures, highlighting the need to efficiently identify marginal livers suitable for transplant. We evaluated the validity of existing non-invasive liver quality tests and a novel machine learning-based model at predicting deceased donor macrosteatosis >30%., Methods: We compared previously-validated non-invasive tests and a novel machine learning-based model to biopsies in predicting macrosteatosis >30%. We also tested them in populations enriched for macrosteatosis., Results: The Hepatic Steatosis Index area-under-the-curve (AUC) was 0.56. At the threshold identified by Youden's J statistic, sensitivity, specificity, positive, and negative predictive values were 49.6%, 58.9%, 14.0%, and 89.7%. Other tests demonstrated comparable results. Machine learning produced the highest AUC (0.71). Even in populations enriched for macrosteatosis, no test was sufficiently predictive., Conclusion: Commonly used clinical scoring systems and a novel machine learning-based model were not clinically useful, highlighting the importance of pre-procurement biopsies to facilitate allocation., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest, (Copyright © 2023. Published by Elsevier Inc.)

Introduction: Menstrual hygiene is a critical issue encountered by women and girls of reproductive age that negatively affects their health and empowerment. It is still deemed a taboo subject in several parts of the world, and girls hesitate to discuss menstruation with their family members, friends, or schoolteachers, which creates hurdles when they experience their menarche. Girls residing in rural areas encounter more problems, since they lack proper resources and knowledge to manage their menstruation in school as well as at home. The purpose of this study was to evaluate the knowledge, attitudes, and practices regarding the menstrual hygiene of girls residing in rural areas of Gilgit, Pakistan., Methods: A descriptive cross-sectional design was used to assess the study questions. The consecutive sampling technique was applied to recruit 300 female participants from remote areas of Gilgit, Pakistan, who were 13 to 22 years old. A pre-tested questionnaire was utilized to collect the data, and SPSS version 21.0 was used to analyze them., Results: The study found that more than half of the participants had a poor level of knowledge and practices and negative attitudes towards menstrual hygiene. This could be due to many cultural and social factors associated with menstrual hygiene., Conclusions: The study concluded that the study participants were not knowledgeable about menstrual hygiene. They had poor practices and attitudes regarding menstrual hygiene. Hence, it is recommended that frequent sessions should be conducted by healthcare workers to enhance the knowledge of parents, teachers, and young girls, to increase their positive attitudes and practices regarding menstrual hygiene.

The benefits of large-scale genetic studies for healthcare of the populations studied are well documented, but these genetic studies have traditionally ignored people from some parts of the world, such as South Asia. Here we describe whole genome sequence (WGS) data from 4806 individuals recruited from the healthcare delivery systems of Pakistan, India and Bangladesh, combined with WGS from 927 individuals from isolated South Asian populations. We characterize population structure in South Asia and describe a genotyping array (SARGAM) and imputation reference panel that are optimized for South Asian genomes. We find evidence for high rates of reproductive isolation, endogamy and consanguinity that vary across the subcontinent and that lead to levels of rare homozygotes that reach 100 times that seen in outbred populations. Founder effects increase the power to associate functional variants with disease processes and make South Asia a uniquely powerful place for population-scale genetic studies., (© 2023. The Author(s).)

Ventilator-associated pneumonia (VAP) is the most common ICU acquired pneumonia among patients who are invasively intubated for mechanical ventilation. Patients with VAP suffer an increased mortality risk, financial burden, and length of stay in the hospital. The authors aimed to review the literature to describe the incidence, mortality, and microbiological evidence of VAP. We selected 13 peer-reviewed articles published from 1 January 2010 to 15 September 2022 from electronic databases for studies among adult or pediatric patients diagnosed with VAP expressed per thousand days admitted in the ICU. The VAP rates ranged from 7 to 43 per thousand days, varying among different countries of the world. A significant rate of mortality was observed in 13 studies ranging from 6.3 to 66.9%. Gram-negative organisms like Acinetobacter spp., Pseudomonas aeruginosa Gram-positive organisms like Staphylococcus aureus were frequently found. Our findings suggest an alarming situation of VAP among patients admitted to the intensive care units with increasing incidence and mortality. The review also found that VAP is more common in males and that there is a significant variation in the incidence and mortality rates of VAP among different countries. The findings of this review can inform the development of infection control and prevention strategies to reduce the burden of VAP. Thus, there is a crucial need for control and preventive measures like interventional studies and educational programs on staff training, hand-hygiene, and the appropriate use of ventilator bundle approach to curb this preventable threat that is increasing at an alarming rate., Competing Interests: All authors declare that they have no conflict of interest with regards to the content of this paper., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Nonalcoholic fatty liver disease (NAFLD) is the commonest type of liver disease worldwide. We aimed to assess the incidence and predictors of liver-related events (LREs) and mortality in NAFLD patients., Methods: NAFLD patients (n = 957) evaluated between January 2000 and November 2021 were included. Patients were categorised as noncirrhosis (NC), compensated cirrhosis (CC) and decompensated cirrhosis (DC), and the incidence of LRE and mortality were estimated and compared., Results: The proportions of NC, CC and DC were 87.8% (n = 840), 8.8% (n = 84) and 3.4% (n = 33), respectively. The median follow-up duration was 3.9 (3.0-5.7) years, and the total cumulative duration was 4633 person-years. The incidence of LRE per 100 person-years was 0.14, 2.72 and 10.24 in patients with NC, CC and DC, respectively. The incidence of mortality was 0.12, 1.05 and 4.24 per 100 person-years, respectively, in the 3 groups. The causes of mortality in the 3 groups were liver related in 1/5 (20%), 3/4 (75%) and 6/9 (66.7%), respectively. Overall, the mortality rate was higher in those with diabetes than those without diabetes (log-rank P value = 0.005). On further analysis, diabetes was associated with poor outcomes only in NC group (log-rank P value = 0.036), and not in CC (log-rank P value = 0.353) or DC groups (log-rank P value = 0.771). On multivariate Cox proportional hazard analysis, age (hazard ratio [HR] 1.070), hypertension (HR 4.361) and DC (HR 15.036) were independent predictors of poor outcomes. Liver stiffness measurement, bilirubin, CC and DC were independent predictors of LRE., Conclusion: In our study of NAFLD from India, the incidence of LRE was found to be similar to that seen in Western studies. In NC NAFLD, diabetes was associated with poor outcomes., (© 2022 Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Background: Donation after cardiac death(DCD) has been proposed as an avenue to expand the liver donor pool., Methods: We examined factors associated with nonrecovery of DCD livers using UNOS data from 2015 to 2019., Results: There 265 non-recovered potential(NRP) DCD livers. Blood type AB (7.8% vs. 1.1%) and B (16.9% vs. 9.8%) were more frequent in the NRP versus actual donors (p < 0.001). The median driving time between donor hospital and transplant center was similar for NRP and actual donors (30.1 min vs. 30.0 min; p = 0.689), as was the percentage located within a transplant hospital (20.8% vs. 20.9%; p = 0.984).The donation service area(DSA) of a donor hospital explained 27.9% (p = 0.001) of the variability in whether a DCD liver was recovered., Conclusion: A number of potentially high quality DCD donor livers go unrecovered each year, which may be partially explained by donor blood type and variation in regional and DSA level practice patterns., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Much of our understanding regarding geographic issues in transplantation is based on statistical techniques that do not formally account for geography and is based on obsolete boundaries such as donation service area., Methods: We applied spatial epidemiological techniques to analyze liver-related mortality and access to liver transplant services at the county level using data from the Centers for Disease Control and Prevention and Scientific Registry of Transplant Recipients from 2010 to 2018., Results: There was a significant negative spatial correlation between transplant rates and liver-related mortality at the county level (Moran's I, -0.319; P  = 0.001). Significant clusters were identified with high transplant rates and low liver-related mortality. Counties in geographic clusters with high ratios of liver transplants to liver-related deaths had more liver transplant centers within 150 nautical miles (6.7 versus 3.6 centers; P  < 0.001) compared with all other counties, as did counties in geographic clusters with high ratios of waitlist additions to liver-related deaths (8.5 versus 2.5 centers; P  < 0.001). The spatial correlation between waitlist mortality and overall liver-related mortality was positive (Moran's I, 0.060; P  = 0.001) but weaker. Several areas with high waitlist mortality had some of the lowest overall liver-related mortality in the country., Conclusions: These data suggest that high waitlist mortality and allocation model for end-stage liver disease do not necessarily correlate with decreased access to transplant, whereas local transplant center density is associated with better access to waitlisting and transplant., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Despite under-reporting, health workers (HWs) accounted for 2 to 30% of the reported COVID-19 cases worldwide. In line with data from other countries, Jordan recorded multiple case surges among HWs., Methods: Based on the standardized WHO UNITY case-control study protocol on assessing risk factors for SARS-CoV-2 infection in HWs, HWs with confirmed COVID-19 were recruited as cases from eight hospitals in Jordan. HWs exposed to COVID-19 patients in the same setting but without infection were recruited as controls. The study lasted approximately two months (from early January to early March 2021). Regression models were used to analyse exposure risk factors for SARS-CoV-2 infection in HWs; conditional logistic regressions were utilized to estimate odds ratios (ORs) adjusted for the confounding variables., Results: A total of 358 (102 cases and 256 controls) participants were included in the analysis. The multivariate analysis showed that being exposed to COVID-19 patients within 1 metre for more than 15 minutes increased three-fold the odds of infection (OR 2.92, 95% CI 1.25-6.86). Following IPC standard precautions when in contact with patients was a significant protective factor. The multivariate analysis showed that suboptimal adherence to hand hygiene increased the odds of infection by three times (OR 3.18; 95% CI 1.25-8.08)., Conclusion: Study findings confirmed the role of hand hygiene as one of the most cost-effective measures to combat the spreading of viral infections. Future studies based on the same protocol will enable additional interpretations and confirmation of the Jordan experience., Competing Interests: The authors have declared that no competing interests exist.

Background: Third time liver transplantation is a technically demanding exercise with variable outcomes in single center series. There has been no national level description of survival following third time liver transplant in the US in the MELD era., Methods: Third time liver transplants between March 1, 2002 and January 1, 2018 in the UNOS dataset were analyzed., Results: Patient survival among the 240 third time liver transplant recipients in the study at 1, 3, 5, and 10 years (71.8%, 62.4%, 59.1%, 49.5%) was significantly worse compared to primary liver transplant (90.6%, 83.9%, 78.8%, 67.6%; p < 0.001) and retransplant (77.1%, 70.3%, 65.6%, 54.9%; p = 0.014). Recipients who were under 43 years old, not on dialysis, without diabetes, and over 1 month out from their second transplant had acceptable survival at 1, 3, 5, and 10 years (88.5%, 78.4%, 73.6%, 69.7%)., Conclusions: While redo-redo transplant remains a challenging endeavor, appropriate patient selection can yield acceptable results., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Despite regulations mandating follow-up laboratory testing for living kidney donors, less than half of transplant centers are in compliance. We sought to understand barriers to follow-up testing from the donors' perspective., Methods: We surveyed our center's living kidney donors. Binary logistic regression was used to assess factors associated with follow-up testing completion., Results: Of 185 living kidney donors, 110 (59.4%) participated. Among them, 82 (74.5%) completed 6-month laboratory testing, 76 (69.1%) completed 12-month testing, 68 (61.8%) completed both, and 21 (19.0%) completed neither. Six-month testing completion was strongly associated with 12-month testing completion (OR 9.74, 95%CI: 2.23-42.50; p = .002). Those who disagreed with the statements, "Getting labs checked wasn't a priority for me," (OR for completing 6-month testing: 15.05, 95%CI: 3.70-61.18; p < .001; OR for completing 12-month testing: 5.85, 95%CI: 1.94-17.63; p = .002); and, "I forgot to get labs drawn [until I was reminded]" (OR for completing 6-month testing: 6.93, 95%CI: 1.59-30.08; p = .01; OR for completing 12-month testing: 6.55, 95%CI: 1.98-21.63; p = .002) were more likely to complete testing., Conclusions: To our knowledge, this is the only study providing perspective on donor insights regarding the need for follow-up testing post donation. Interventions to influence living donor attitudes toward follow-up testing may improve follow-up., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Estimation of fetal weight during pregnancy plays an important role in prenatal and intrapartum care and is more important in pregnancies after 37 weeks to determine the type of delivery. The aim of this study was to compare and evaluate the accuracy and diagnostic value of two-dimensional ultrasound and clinical examination in estimating fetal weight and pregnancy outcomes., Materials and Methods: This cross-sectional study was conducted on 300 pregnant women without abnormal fetuses and pregnancies after 37 weeks; mothers who had a normal delivery or cesarean section were evaluated by the available method. The weight of the fetus was estimated before and after delivery, using ultrasound and clinical examination. Newborns were classified into five groups based on their fetal weight. Analysis of collected data was performed with SPSS software., Results: The mean age of the patients was 31 years and the mean weight of the neonates was 3450 g. At a weight of less than 3000 g, ultrasound and clinical evaluation were strongly correlated with the actual weight of the infant, but at weights of more than 3500 and 4000 g, weight estimation with ultrasound was highly accurate, and clinical examination had poor accuracy. In lower weights, square errors were fewer in both ultrasound and clinical examination, in comparison with higher weights. In higher weights, ultrasound is more reliable, and the diagnostic accuracy of clinical examination is reduced., Conclusion: Estimation of fetal weight with prenatal ultrasound is highly accurate. Clinical examination is more accurate in determining the weight of small fetuses and does not pay much attention to the diagnosis of macrosomic fetuses and even leads to overestimation, while ultrasound is much more accurate in diagnosing fetal macrosomia., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Family Medicine and Primary Care.)

Introduction: The pediatric obesity epidemic is associated with early development of hepatic macrosteatosis, a hallmark of non-alcoholic fatty LI disease, which is thought to be more rapidly progressive in children than adults. Macrosteatosis in adult allografts is associated with allograft loss, but this has not been examined in pediatric donors., Methods: We studied all pediatric potential whole LI donors (2005-2018) who had a LI biopsy in the SRTR (n = 862) and whose LI was transplanted (n = 862). Macrosteatosis was abstracted from biopsy reports and compared to values in the SRTR standard analytic file. Recipients of macrosteatotic pediatric allografts were matched 1:1 to recipients of non-macrosteatotic pediatric allografts by propensity score matching on donor/recipient variables. All-cause allograft loss was estimated via Kaplan-Meier analysis and Cox proportional hazards model., Results: From 2005 to 2018, the proportion of pediatric donors (age ≥2 years) with obesity increased (14.8% to 21.7%; p < .001), as did the proportion of pediatric deceased whole LI-only donor allografts with macrosteatosis (n = 10 648; 1.8% to 3.9%; p < .001). The median degree of macrosteatosis among macrosteatotic donors was 10% (IQR 5-30). There were no significant differences in all-cause allograft loss between recipients of pediatric LI allografts with and without macrosteatosis at 90 days (p = .11) or 1 year (p = .14) post-transplant in Kaplan-Meier analysis or a Cox proportional hazards model (p > .05)., Conclusion: Obese pediatric LI donors have increased over time and were more likely to have hepatic macrosteatosis; however, pediatric macrosteatosis did not appear to adversely affect recipient outcomes., (© 2021 Wiley Periodicals LLC.)

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Objective: We aimed to evaluate treatment responses and recurrence rate of atypical endometrial hyperplasia (AEH) and endometrial endometrioid adenocarcinoma (EA) with Stage IA Grade 1 to megestrol in Iranian patients who are candidates for medical treatments., Methods: In a retrospective cohort study that was conducted on 50 patients with AEH and 22 patients with EA who were referred to the oncology clinic of Imam Khomeini Hospital, Tehran, Iran, during 2006-2016, we recruited all patients with AEH or EA of Stage IA Grade 1 and their disease was diagnosed during endometrial curettage with or without hysteroscopy. Patients were initially treated with 160 mg of megestrol daily, along with aspirin up to 3 months, and then after 3-4 weeks of discharge of the drugs, patients underwent curettage with hysteroscopy., Findings: The patients with AEH had 31 complete responses and five progressive diseases, and the patients with EA had seven complete responses and seven progressive diseases. After treatment, 25 cases with AEH and 5 cases with EA had an intention to get pregnant, whereas eight patients with AEH and 1 case with endometrial cancer became pregnant. Recurrence occurred in the 2 cases with AEH and 2 cases with endometrial cancer which the time of recurrence in the patients with AEH was longer than in patients with endometrial cancer ( P = 0.011)., Conclusion: Megestrol is an effective therapeutic agent in endometrial hyperplasia or low-grade endometrial cancer patients who are willing to conserve their childbearing., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Research in Pharmacy Practice.)

Objectives: To conduct a descriptive clinicopathological and demographic analysis of dermatofibrosarcoma protuberans among Saudi patients attending a tertiary care center in the eastern province of Saudi Arabia., Methods: This retrospective, single-center study reviewed the medical records and pathology reports of Saudi patients attending a tertiary center (Johns Hopkins Aramco Health Care) in Dhahran, Saudi Arabia from 1995 to 2019 to identify all cases of dermatofibrosarcoma protuberans. Demographic and phenotypic data were also analyzed., Results: Thirty-five Saudi patients were identified as having dermatofibrosarcoma protuberans. Females constituted 68.6% of patients. The trunk was the most common site of involvement (54.3%), followed by the lower extremities (34.3%), upper extremities (8.6%), and head and neck (2.9%). The mean tumor size was 2.9 cm (standard deviation: ±2.0). There was only one case of distant metastasis of fibrosarcomatous dermatofibrosarcoma protuberans., Conclusions: Dermatofibrosarcoma protuberans was not frequently encountered in Saudi patients in a tertiary center that treats approximately 187,668 patients. Dermatofibrosarcoma protuberans disease patterns and demographic data were similar to those reported worldwide. Further studies are required to characterize dermatofibrosarcoma protuberans in the Saudi population., (Copyright: © Saudi Medical Journal.)

The bioleaching process is developing as an economic and successful biotechnology method in the metallurgy industry. Acidithiobacillus ferrooxidans is one of the most important bacteria involved in uranium bioleaching which converts insoluble U 4+ to soluble U 6+ by oxidation of Fe 2+ to Fe 3+ using several periplasmic proteins encoded by the genes in rus and petI operons in its electron transport pathway. Accordingly, the purpose of this study was to consider the expression of these genes through exposed A. ferrooxidans sp. FJ2 to γ-ray in 17 different doses targeting uranium extraction yield. Acidithiobacillus ferrooxidans sp. FJ2 was irradiated by gamma rays at 25, 50, 75, 100, 150, 300, 450, 600, 750 Gy and 1, 2, 5, 10, 15, 20, 25 and 30 kGy doses. Moreover, the Eh value of 9k culture media was measured as special screening criteria to select the four treatments. The selected bacteria were cultured in 9k media, containing 50% uranium ore powder in the bioleaching process. Then, the value of pH & Eh of culture media, Fe 2+ and uranium concentrations in 4, 8 and 13 day's period of incubation were measured. In followings, the expression levels of cyc1, cyc2, rus, coxB, petA, petB, petC and cycA genes at the end of each period were investigated by real-time PCR. Overall, all samples demonstrated a decrease in pH value and Fe 2+ concentration and an increase in Eh value and U concentration in time intervals. The gamma irradiation in given doses raised the expression levels of all genes encoded in rus and petI operons, except petB gene during the bioleaching process, although, it had no effect either on the pH, Eh values or on Fe 2+ and uranium concentrations. This result implies that during the oxidation of ferrous iron and formation of Jarosite sediment, the decreasing trend of pH and the increasing trend of Eh occurred in all samples. However, the differences in expression of the genes of rus and petI operons in the samples did not have an effect on uranium extraction., (Copyright © 2021. Published by Elsevier Ltd.)

Purpose of Review: Transplantation is the life-saving therapy for patients suffering from end-organ failure, and as such, equitable access to transplantation (ATT) is of paramount importance. Unfortunately, gender/sex-based disparities exist, and despite the transplant community's awareness of this injustice, gender/sex-based disparities have persisted for more than two decades. Importantly, no legislation or allocation policy has addressed inequity in ATT that women disproportionately face. In fact, introduction of the model for end-stage liver disease-based liver allocation system in 2002 widened the gender disparity gap and it continues to be in effect today. Moreover, women suffering from kidney disease are consistently less likely to be referred for transplant evaluation and subsequently less likely to achieve a kidney transplant, yet they comprise the majority of living kidney donors., Recent Findings: Acknowledging gender/sex-based disparities in ATT is the first step toward interventions aimed at mitigating this long-standing injustice in healthcare., Summary: This article provides a background of end-stage liver and kidney disease in women, summarizes the existing literature describing the issue of gender disparity in ATT, and identifies potential areas of intervention and future investigation., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: The aim of this study was to characterize end-stage renal disease (ESRD) patients with obesity as their only contraindication to listing and to quantify wait-list and transplant access., Methods: Using the US Renal Data System, a retrospective cohort study of incident dialysis cases (2012 to 2014) was performed. The primary outcomes were time to wait-listing and time to transplantation., Results: Of 157,572 dialysis patients not already listed, 39,844 had BMI as their only demonstrable transplant contraindication. They tended to be younger, female, and Black. Compared with patients with BMI < 35, those with BMI 35 to 39.9, 40 to 44.9, and ≥45 were, respectively, 15% (adjusted hazard ratio [aHR] 0.85; 95% CI: 0.83-0.88; p < 0.001), 45% (aHR 0.55; 95% CI: 0.52-0.57; p < 0.001), and 71% (aHR 0.29; 95% CI: 0.27-0.31; p < 0.001) less likely to be wait-listed. Wait-listed patients with BMI 35 to 39.9 were 24% less likely to achieve transplant (aHR 0.76; 95% CI: 0.72-0.80; p < 0.0001), BMI 40 to 44.9 were 21% less likely (aHR 0.79; 95% CI: 0.72-0.86; p < 0.0001), and BMI ≥ 45 were 15% less likely (aHR 0.85; 95% CI: 0.75-0.95; p = 0.004) compared with patients with BMI < 35., Conclusions: Obesity was the sole contraindication to wait-listing for 40,000 dialysis patients. They were less likely to be wait-listed. For those who were, they had a lower likelihood of transplant. Aggressive weight-loss interventions may help this population achieve wait-listing and transplant., (© 2021 The Obesity Society.)

Objective: To analyze and quantify sacral spinal excitability through bulbocavernosus reflex (BCR) stimulus-response curves., Methods: Thirty subjects with upper motor neuron lesions (UMN) and nine controls were included in this prospective, monocentric study. Sacral spinal excitability was assessed using stimulus-response curves of the BCR, modeled at different bladder filling volumes relative to the desire to void (as defined by the International Continence Society) during a cystometry. Variations in α (i.e. the slope of the stimulus-response curve) were considered as an indicator of the modulation of sacral spinal excitability., Results: In all subjects, α increased during bladder filling suggesting the modulation of spinal sacral excitability during the filling phase. This increase was over 30% in 96.7% of neurological subjects and 88.9% of controls. The increase was higher before the first sensation to void in the neurological population (163.15%), compared to controls, (29.91%), p < 0.001., Conclusions: We showed the possibility of using BCR stimulus-response curves to characterize sacral spinal response with an amplification of this response during bladder filling as well as a difference in this response amplification in patients with UMN in comparison with a control group., Significance: BCR, through stimulus-response curves, might be an indicator of pelvic-perineal exaggerated reflex response and possibly a tool for evaluating treatment effectiveness., 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 © 2021 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Background: Community-based strategies to promote maternal health can help raise awareness of pregnancy danger signs and preparations for emergencies. The objective of this study was to assess change in birth preparedness and complication readiness (BPCR) and pregnant women's knowledge about pre-eclampsia as part of community engagement (CE) activities in rural Pakistan during the Community Level Interventions for Pre-eclampsia (CLIP) Trial., Methods: The CLIP Trial was a cluster randomized controlled trial that aimed to reduce maternal and perinatal morbidity and mortality using CE strategies alongside mobile health-supported care by community health care providers. CE activities engaged pregnant women at their homes and male stakeholders through village meetings in Hyderabad and Matiari in Sindh, Pakistan. These sessions covered pregnancy complications, particularly pre-eclampsia/eclampsia, BPCR and details of the CLIP intervention package. BPCR was assessed using questions related to transport arrangement, permission for care, emergency funds, and choice of facility birth attendant for delivery during quarterly household surveys. Outcomes were assessed via multilevel logistic regression with adjustment for relevant confounders with effects summarized as odds ratios and 95% confidence intervals., Results: There were 15 137 home-based CE sessions with pregnant women and families (n = 46 614) and 695 village meetings with male stakeholders (n = 7784) over two years. The composite outcomes for BPCR and pre-eclampsia knowledge did not differ significantly between trial arms. However, CE activities were associated with improved pre-eclampsia knowledge in some areas. Specifically, pregnant women in the intervention clusters were twice as likely to know that seizures could be a complication of pregnancy (odds ratio (OR) = 2.17, 95% confidence interval (CI)  = 1.11, 4.23) and 2.5 times more likely to know that high blood pressure is potentially life-threatening during pregnancy (OR = 2.52, 95% CI = 1.31, 4.83) vs control clusters., Conclusions: The findings suggested that a CE strategy for male and female community stakeholders increased some measures of knowledge regarding complications of pre-eclampsia in low-resource settings. However, the effect of this intervention on long-term health outcomes needs further study., Trial Registration: Clinical Trials.gov - INCT01911494., Competing Interests: Competing interests: The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author), and declare no conflicts of interest., (Copyright © 2021 by the Journal of Global Health. All rights reserved.)

Background: Intestinal ostomy creation after trauma is selectively indicated for destructive colon and rectal injuries. However, the nationwide rates of creation of ostomies for trauma and their reversal are not known. The objective of this study was to ascertain national estimates of trauma ostomy creation and reversal., Methods: Weighted analysis of Healthcare Cost and Utilization Project Nationwide Readmissions Database 2014 to 2015 was performed. Adult trauma patients (≥16 years) with a hollow viscus injury were included. Patients with preexisting ostomies and permanent ostomies and those who died within 48 hours of admission were excluded. Rates of ostomy creation and same admission ostomy reversal were calculated. Rates of postdischarge ostomy reversal were calculated using the Kaplan-Meier estimator. Multivariable Cox proportional hazards model was used to determine factors associated with postdischarge trauma ostomy reversal., Results: A total of 22,542 patients sustained a hollow viscus injury resulting in the creation of 2,145 ostomies (9.6%). The rate of same-admission ostomy reversal was 0.7% (n = 16). At 1, 3, 6, and 9 months, the cumulative stoma reversal rates were 0%, 7.6%, 31.0%, and 43.1%, respectively. The mean ± SD time from ostomy creation to reversal was 123 ± 6.7 days for those undergoing reversal. Injury Severity Score greater than 9 was significantly associated with ostomy nonreversal after discharge (hazard ratio, 0.41; 95% confidence interval, 0.26-0.66). Age, sex, insurance status, penetrating injury, Charlson Comorbidity Index, and hospital teaching status were not significantly associated with ostomy reversal., Conclusion: The nationwide rate of ostomy creation after trauma is nearly 10%. At 6 months postinjury, only one third of patients had undergone ostomy reversal. Future study is needed to understand patient and provider-level factors associated with trauma ostomy reversal., Level of Evidence: Epidemiology, level III., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Influenza illness burden is substantial, particularly among young children, older adults, and those with underlying conditions. Initiatives are underway to develop better global estimates for influenza-associated hospitalizations and deaths. Knowledge gaps remain regarding the role of influenza viruses in severe respiratory disease and hospitalizations among adults, particularly in lower-income settings., Methods and Findings: We aggregated published data from a systematic review and unpublished data from surveillance platforms to generate global meta-analytic estimates for the proportion of acute respiratory hospitalizations associated with influenza viruses among adults. We searched 9 online databases (Medline, Embase, CINAHL, Cochrane Library, Scopus, Global Health, LILACS, WHOLIS, and CNKI; 1 January 1996-31 December 2016) to identify observational studies of influenza-associated hospitalizations in adults, and assessed eligible papers for bias using a simplified Newcastle-Ottawa scale for observational data. We applied meta-analytic proportions to global estimates of lower respiratory infections (LRIs) and hospitalizations from the Global Burden of Disease study in adults ≥20 years and by age groups (20-64 years and ≥65 years) to obtain the number of influenza-associated LRI episodes and hospitalizations for 2016. Data from 63 sources showed that influenza was associated with 14.1% (95% CI 12.1%-16.5%) of acute respiratory hospitalizations among all adults, with no significant differences by age group. The 63 data sources represent published observational studies (n = 28) and unpublished surveillance data (n = 35), from all World Health Organization regions (Africa, n = 8; Americas, n = 11; Eastern Mediterranean, n = 7; Europe, n = 8; Southeast Asia, n = 11; Western Pacific, n = 18). Data quality for published data sources was predominantly moderate or high (75%, n = 56/75). We estimate 32,126,000 (95% CI 20,484,000-46,129,000) influenza-associated LRI episodes and 5,678,000 (95% CI 3,205,000-9,432,000) LRI hospitalizations occur each year among adults. While adults <65 years contribute most influenza-associated LRI hospitalizations and episodes (3,464,000 [95% CI 1,885,000-5,978,000] LRI hospitalizations and 31,087,000 [95% CI 19,987,000-44,444,000] LRI episodes), hospitalization rates were highest in those ≥65 years (437/100,000 person-years [95% CI 265-612/100,000 person-years]). For this analysis, published articles were limited in their inclusion of stratified testing data by year and age group. Lack of information regarding influenza vaccination of the study population was also a limitation across both types of data sources., Conclusions: In this meta-analysis, we estimated that influenza viruses are associated with over 5 million hospitalizations worldwide per year. Inclusion of both published and unpublished findings allowed for increased power to generate stratified estimates, and improved representation from lower-income countries. Together, the available data demonstrate the importance of influenza viruses as a cause of severe disease and hospitalizations in younger and older adults worldwide., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: H.N.: Grants from the Foundation for Influenza Epidemiology, grants from Innovative Medicines Initiative, grants from the WHO, personal fees from Bill and Melinda Gates Foundation, grants and personal fees from Sanofi, grants from National Institute of Health Research, personal fees from Janssen and personal fees from AbbVie, outside the submitted work. The remaining authors have declared that no competing interests exist.

A growing body of evidence demonstrates that the oncogenic miRNAs are critical components that are involved in breast cancer (BC) progression. Thus, they are attracting a great deal of consideration as they provide opportunities for the novel avenues for developing BC targeted therapy. In the current review, we try to discuss the key oncogenic miRNAs implicated in cell migration, invasion and metastasis (e.g., miR-9, miR-10b, miR-10b-5p, miR-17/9, miR-21, miR-103/107, miR-181b-1, miR-301, miR-301a, miR-373, miR- 489, miR-495 and miR-520c), apoptosis inhibition (e.g., miR-21, miR-155, miR-181, miR-182 and miR-221/222), cell proliferation (e.g., miR-221/222, miR-17/92, miR-21, miR-301a, miR-155, miR-181 b, miR-182, miR-214, miR-20b, miR-29a, miR-196, miR-199a-3p, miR- 210, miR-301a, miR-375, miR-378-3p and miR-489), and angiogenesis (e.g., miR-9, miR-17/92 cluster, miR-93 and miR-210). In particular, here, we considered miRNA-based therapeutic approaches to summarize the evidence for their potential therapeutic uses in clinical practice. Therefore, miRNA mimics (i.e., replacement and restoration of miRNAs) and inhibition therapy (e.g., anti-miRNA oligonucleotides (AMO), antagomiRs or antisense oligonucleotides (ASOs): cholesterol-conjugated anti-miRs and locked nucleic acid (LNA)), miRNA sponges, nanoparticles (NPs), multiple-target anti-mirna antisense oligonucleotide technology (MTg-AMOs), and artificial miRNAs (amiRNAs) have been indicated throughout the article as much as possible.

Aims: Kikuchi-Fujimoto disease (KFD) is a self-limited disease characterised by destruction of the lymph node parenchyma. Few studies have assessed the immunohistological features of KFD, and most employed limited antibody panels that lacked many of the novel immunohistochemistry markers currently available., Methods and Results: We used immunohistochemistry to reappraise the microanatomical distribution of plasmacytoid dendritic cells (pDCs), follicular helper T cells and cytotoxic T cells, B cells, follicular dendritic cell (FDC) meshworks, and histiocytes in lymph nodes involved by KFD. The study group consisted of 138 KFD patients (89 women; 64.5%) with a median age of 27 years (range, 3-50 years). Cervical lymph nodes were most commonly involved, in 108 (78.3%) patients. The numbers of pDCs were increased, predominantly around and within apoptotic areas and the paracortex, and tapering off within xanthomatous areas. pDCs formed sizeable tight clusters, most notably around apoptotic/necrotic areas. T cells consisted mostly of CD8-positive cells with predominant expression of T-cell receptor-β. There were notable increases in the numbers of CD8-positive T cells within lymphoid follicles, and their numbers correlated with alterations in FDC meshworks (P < 0.001). The number of follicular helper T cells was decreased within distorted FDC meshworks. CD21 highlighted frequent distortion of FDC meshworks, even in lymph node tissue that was distant from apoptotic/necrotic areas. Distorted FDC meshworks spanned all morphological patterns, and FDC meshwork characteristics (intact; distorted; remnant/nearly absent) correlated with morphological patterns (P < 0.01)., Conclusions: The immunohistological landscape of KFD is complex and characterised by increased numbers of pDCs that frequently cluster around apoptotic/necrotic foci, increased numbers of cytotoxic T cells, and substantial distortion of FDC meshworks., (© 2020 John Wiley & Sons Ltd.)

Background: Malnutrition is one of the most common causes of morbidity and mortality among children and adolescents and is now considered to be one of the largest risk factors responsible for the global burden of diseases along with poor diet., Objectives: The objective of this review was to assess the impact of preventive nutrition interventions (including nutrition education and counselling; micronutrient supplementation/fortification and macronutrient supplementation) to improve the health and nutritional status of adolescents aged 10-19 years in low- and middle-income countries (LMICs). The secondary objective of the review was to assess various contextual factors based on the World Health Organisation (WHO) health system building blocks framework that might potentially impact the effectiveness of these interventions for this age group., Search Methods: The search was conducted on Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, the WHO nutrition databases, CAB Global Health, Social Science Citation Index, Scopus, WHO Global Health Index, ADOLEC and EPPI until February 5, 2019. We searched Google Scholar along with key nutrition agencies database such as Nutrition International, the Global Alliance for Improved Nutrition, the World Food Programme and HarvestPlus to search for nonindexed, grey literature to locate relevant programme evaluations and any additional trials. All searches were performed without any restrictions on publication date, language or publication status., Selection Criteria: We included randomised controlled trials, quasiexperimental studies, controlled before-after studies and interrupted time series evaluating the effectiveness of preventive nutrition interventions among adolescents between 10 and 19 years of age from LMICs., Data Collection and Analysis: Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data from included studies. Meta-analysis was conducted separately for each outcome and intervention. For dichotomous data, we reported risk ratios (RR) with 95% confidence intervals (CI). For continuous data, we reported the mean difference (MD) or standard mean difference (SMD) with 95% CI., Main Results: This review summarises findings from a total of 10 studies from 15 papers including 10,802 participants. All the studies included in this review assessed the impact of micronutrient supplementation/fortification on health and nutritional status among adolescents in LMIC. We did not find any study assessing the impact of nutrition education and counselling or on macronutrient supplementation among adolescents. Micronutrient supplementation/fortification interventions included calcium/vitamin D supplementation/fortification, iron supplementation with or without folic acid, zinc supplementation and multiple micronutrient (MMN) fortification. The majority of the studies (eight out of 10 studies) included adolescent girls aged between 10 and 19 years of age. We did not find any large scale preventive nutrition intervention programmes targeting adolescents in LMICs. We are uncertain of the effect of iron supplementation with or without folic acid on anaemia (daily supplementation; RR: 1.04, 95% CI 0.88, 1.24; one study; 1,160 participants; low quality evidence. Weekly supplementation; RR: 1.07, 95% CI: 0.91, 1.26; one study; 1,247 participants; low quality evidence). We are uncertain of the effect of various micronutrient supplementation/fortification on body mass index (calcium/vitamin D supplementation; (MD: -0.01 kg/m 2 ; 95% CI: -1.20, 1.17; two studies; 730 participants; I 2 94%; very low quality evidence, iron supplementation with or without folic acid; MD: 0.29 kg/m 2 ; 95% CI: -0.25, 0.83; two studies; 652 participants; I 2 69%; very low quality evidence, zinc supplementation; MD: 0.35 kg/m 2 ; 95% CI: -0.15, 0.85; one study; 382 participants; very low quality evidence) and MMN fortification; MD: 0.23 kg/m 2 , 95% CI: -0.11, 0.57; two studies; 943 participants; I 2 22%; very low quality evidence). None of the included studies reported any other primary outcomes including morbidity or adverse effects. Iron supplementation with or without folic acid may improve haemoglobin concentrations (MD: 0.42 g/dL, 95% CI: 0.13, 0.71; four studies; 1,020 participants; I 2 89%; low quality evidence). Calcium/vitamin D supplementation may improve serum 25(OH) D levels (standardised mean difference [SMD]: 2.85, 95% CI: 0.89, 4.82; two studies; 395 participants; I 2 99%; low quality evidence). We are uncertain of the effect of calcium only supplementation (MD: 0.02 g/cm 2 , 95% CI: -0.00, 0.04; one study; 233 participants; low quality outcome) and calcium + vitamin D supplementation (MD: 0.02 g/cm 2 , 95% CI: -0.00, 0.04; one study; 235 participants; low quality evidence) on total bone mineral density (BMD). We are uncertain of the effect of MMN fortification on haemoglobin concentrations (MD: -0.10 g/dL, 95% CI: -0.88, 0.68; two studies; 1102 participants; I 2 100%; very low quality evidence); calcium supplementation on total body bone mineral content (BMC); (MD: 30.20 g, 95% CI: -40.56, 100.96; one study; 233 participants; low quality evidence), calcium + vitamin D supplementation on total body BMC (MD: 21.60 g, 95% CI: -45.32, 88.52; one study; 235 participants; low quality evidence) and zinc supplementation on serum zinc levels (SMD: 6.94, 95% CI: -4.84, 18.71; two studies; 494 participants; very low quality evidence). One study reported the impact of iron supplementation with or without folic acid on cognition of adolescent girls suggesting improved cognition in most of the tests with daily or twice weekly supplementation compared to once weekly or no supplementation. None of the other secondary outcomes were reported including any other development outcomes and all-cause mortality. These findings warrant caution while interpreting due to very few studies and high heterogeneity., Authors' Conclusions: There is limited evidence of micronutrient supplementation/fortification among adolescents on health and nutritional status in LMICs, with lack of evidence on nutrition education and counselling and macronutrient supplementation. The findings are generaliseable for adolescent girls since all studies (except one) targeted female adolescents., Competing Interests: The authors declare that there are no conflict of interests., (© 2020 The Authors. Campbell Systematic Reviews published by John Wiley & Sons Ltd on behalf of The Campbell Collaboration.)

Objective: To determine the types of paraproteins in patients with multiple myeloma in a tertiary care setting., Methods: The cross-sectional study was conducted at the Liaquat National Hospital, Karachi, from November 2015 to May 2016, and comprised patients with multiple myeloma selected using consecutive, non-probability sampling technique. Detailed history was taken and immunofixation assay was conducted to assess the type of paraproteins in the patients. Data was recorded on a proforma and analysed using SPSS 22., Results: Of the 87 patients, 62(71.3%) were males and 25(28.7%) were females. The overall mean age was 57.41±10.53 years. Of the total, 52(71.3%), patients had Immunoglobulin G kappa and 61(70%) had Immunoglobulin A kappa paraprotein., Conclusions: The most common types of paraprotein was found to be Immunoglobulin G kappa followed by Immunoglobulin A kappa.

The objective of this review was to assess the impact of preventive nutrition interventions on health and nutritional status of adolescents aged 10-19 years in low- and middle-income countries (LMICs). We searched the databases until 5 February 2019 without any restrictions on publication, date, language, or publication status. A total of 10 studies (15 papers) including 10,802 participants assessing the impact of micronutrient supplementation/fortification were included in this review. We did not find any study assessing the impact of nutrition education and counseling or macronutrient supplementation among adolescents. Among primary outcomes, we are uncertain of the effect of iron supplementation with or without folic acid on anemia (daily supplementation; relative risk (RR): 1.04, 95% confidence interval (CI) 0.42, 2.57; one study; 1160 participants; low-quality evidence; weekly supplementation; RR: 1.07, 95% CI: 0.46, 2.52; one study; 1247 participants; low-quality evidence). We are also uncertain of the effect of various micronutrient supplementation/fortification on body mass index (BMI) (calcium/vitamin D supplementation; (MD: -0.01 kg/m 2 ; 95% CI: -1.20, 1.17; two studies; 730 participants; I 2 94%; very-low-quality evidence, iron supplementation with or without folic acid; MD: 0.47 kg/m 2 ; 95% CI: -0.17, 1.11; two studies; 652 participants; I 2 37%; very-low-quality evidence, zinc supplementation; MD: 0.35 kg/m 2 ; 95% CI: -0.15, 0.85; one study; 382 participants; very-low-quality evidence) and multiple micronutrient (MMN) fortification; MD: 0.23 kg/m 2 , 95% CI: -0.11, 0.57; two studies; 943 participants; I 2 22%; very-low-quality evidence). None of the included studies reported any other primary outcomes including morbidity or adverse effects. Among secondary outcomes, iron supplementation with or without folic acid may improve hemoglobin concentrations, and calcium/vitamin D supplementation may improve serum 25(OH)D levels, while calcium only supplementation and calcium and vitamin D supplementation may marginally improve total body bone mineral density (BMD). We are uncertain of the effect of MMN fortification on hemoglobin concentrations, calcium supplementation on total body bone mineral content (BMC), calcium + vitamin D supplementation on total body BMC, and zinc supplementation on zinc levels. There is limited evidence of micronutrient supplementation/fortification among adolescents, especially adolescent boys, on health and nutritional status in LMICs. These findings should be interpreted with caution due to the low quality and limited number of studies.

Coronary artery disease (CAD) has significant social and economic implications. It is necessary to create tools to identify the most cost-effectiveness treatments, which can assist clinicians in their therapeutic decisions so that the maximum possible benefit is reached with the lowest possible cost. Effectiveness must be measured by final treatment goals in which the most effective interventions are those with the lowest costs. This study is aimed to systematically review and compare the studies conducted on the cost-effectiveness of the three coronary artery disease treatment strategies (medical treatment, percutaneous coronary intervention, and coronary artery bypass graft). In this systematic review, the databases NHS Economic Evaluation Database, Embase, MEDLINE, Science Direct, and Scopus were searched for studies on the cost-effectiveness of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) compared to medical therapy (MT) in patients with coronary artery disease between 1 January 2004 to 30 September 2018. The quality appraisal of the included studies was examined using the Consolidated Health Economics Evaluation Reporting Standards (CHEERS) statement. Out of 186 unique retrievals, 8 studies were included. The results showed that the all studies clearly stated the time horizon of the study and included direct medical costs in their analysis. In addition, in most of the studies, quality-adjusted life years (QALY) were the main outcome used for measuring the effectiveness. The studies reported various ranges of the incremental cost-effectiveness ratio (ICER); accordingly, the highest ratio was observed in the USA ($212,800) for PCI v MT and the lowest ratio was observed in Brazil ($4403) for CABG v MT. Although the results of the studies were different in terms of a number of aspects, such as the viewpoint of the study, the study horizons, and the costs of expenditure items, they reached similar results. Based on the result of the present study, it seems that each three treatment strategies for CAD yielded improvements in QALY.

Objectives: To assess the effect of urine stream interruption exercise on micturition., Methods: This study was conducted prospectively in female patients without urinary disorders. Two uroflowmetries were performed: one during a usual micturition and one during an exercise of urine stream interruption. For the urine stream interruption exercise the subject was asked to begin the micturition, to stop it at 3 s, when the stream is interrupted, to start voiding again, then again stop it at 3 s and repeat this manoeuvre until the end of the micturition., Results: Twenty female patients (mean age 38.7 years old, SD 12.3) were included. Post void residual volume was higher after the urine stream interruption micturition (mean 36.7 mL, SD 46.6) than during standard micturition (mean 8.2 mL, SD 24.1) (P = 0.02). During normal voiding, the maximal flow rate was higher (26.9 mL/min vs 17.8 mL/min; P < 0.0001). There was no difference concerning neither the voiding volume nor the slope of ascending part of flow curve. During urine stream interruption micturition, the flow rate slope, the voiding volume and the maximal flow rate by voiding sequence were decreasing as the voiding sequences followed each other., Conclusions: Urine stream interruption increases the post-void residual volume and translates into less efficient micturition. Thus, it should not be used in current practice of pelvic floor muscles training., (© 2019 The Japanese Urological Association.)