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Background: Tourism is important to the Jamaican economy accounting for approximately 25% of the gross domestic product. Health problems in tourists could have significant impact on the health of the local population, the scarce health service resources, and the tourist industry. This study was conducted to identify health problems most commonly occurring in tourists visiting Jamaica and examine how these problems are managed.Methods: Records of health problems occurring in tourists who visited principal tourist areas on the north coast from June 1998 to June 2002 were reviewed for the type of illness and how the problem was handled. The data were analyzed using Epi-Info software (Centers for Disease Control and Prevention, Atlanta, GA) and Statistical Analysis System software (SAS Institute, Cary, NC).Results: Accidents were the most common health crises reported by tourists. Gastrointestinal, respiratory, and cardiovascular problems occurred less frequently. Those less than 40 years of age more frequently reported accidents or injury, gastrointestinal problems, and drug abuse, whereas respiratory and cardiovascular problems were more common among those above 40 years of age. Cardiovascular problems, drug abuse, and death were more common in men than in women. Hotel nurses handled most of the cases and were more likely to refer patients to private physicians or hospitals than to public hospitals (p <.05). Factors influencing the way the crisis was handled were age (p =.0441); who handled the crisis (p <.0001); and the method of payment (p =.0072). The factors that influenced hospitalization were gender (p =.0615); who handled the crisis at the onset (p =.0497); how the crisis was dealt with (p =.0336); and previous health problems (p =.0056). Men were more likely to be hospitalized and to be referred to a public hospital than women. Medical insurance covered the costs for 11% of tourists, and 75% paid out of pocket.Conclusion: The information provided by this study can be used to implement changes to reduce health problems in tourists and improve emergency health services in tourist areas. [ABSTRACT FROM AUTHOR]

Background: Frailty has been associated with worse postoperative outcomes. The 5-factor modified frailty index (mFI-5) is an objective measure although its validity in measuring frailty in patients undergoing ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC) has not been reported., Methods: This study used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted proctectomy database. The mFI-5 was calculated by five preoperative diagnoses: insulin-dependent or noninsulin-dependent diabetes, congestive heart failure, hypertension, chronic obstructive pulmonary disease, and dependent or partially dependent functional status. The impact of mFI-5 on minor and major postoperative morbidity in CUC patients undergoing IPAA was analyzed., Results: The cohort included 1454 patients (median age 38 years, median body mass index [BMI] 26 kg/m2) of which 87 % had a mFI-5 = 0, 11 % had a mFI-5 = 1, and 2.5 % a mFI-5 ≥ 2. In multivariable logistic regression, mFI-5 ≥ 2 was significantly associated with minor complications (OR = 2.29, 95 % CI [1.00-5.22], p  = 0.049), but not with major complications ( p  = 0.860)., Conclusion: IPAA for CUC is associated with high postoperative morbidity, however, the mFI-5 alone has limited utility in determining which patients are at a higher risk of complications due to frailty. These observations suggest there is a need for more relevant instruments to measure frailty in this patient cohort., Competing Interests: The authors have no conflicts of interest to declare., (© 2024 Published by Elsevier Inc.)

Background: Ileal pouch anal anastomosis is the treatment of choice for patients with chronic ulcerative colitis and familial adenomatous polyposis undergoing a proctocolectomy and desiring bowel continuity. It is a technically complex operation associated with significant morbidity and may be performed by an open, laparoscopic, or robotic approach. However, there is a paucity of data regarding the comparative perioperative outcomes between these 3 techniques outside of institutional studies., Methods: The NSQIP targeted proctectomy data set was used to identify patients who underwent open, laparoscopic, and robotic ileal pouch anal anastomosis between 2016 and 2019. Thirty-day outcomes between different surgical approaches were compared using univariate and multivariable analysis., Results: During the study period, 1,067 open, 971 laparoscopic, and 341 robotic ileal pouch anal anastomosis were performed. The most frequent indications were inflammatory bowel disease (64%), malignancy (18%), and familial adenomatous polyposis (7%). Mean age of the cohort was 43 ± 15 years with 43% female and 76% with body mass index ≤ 30 kg/m 2 . Overall morbidity was 26.8% for the entire cohort with 4% anastomotic leak, 6% reoperation, 21% ileus, and 21% readmission rate. After adjusting for available confounders, operative approach was not associated with better short-term outcomes, including length of stay, overall morbidity, anastomotic leak, reoperation, incidence of ileus, and 30-day readmissions., Conclusion: Ileal pouch anal anastomosis continues to be associated with significant postoperative morbidity regardless of operative approach. Patient-related advantages in terms of perioperative outcomes for laparoscopic and robotic platforms compared to open surgery are less pronounced in complex operations such as ileal pouch anal anastomosis., (© 2022 The Authors.)

Introduction and Importance: Epidermal inclusion cysts are a common benign finding, and they are predominantly asymptomatic. They can rarely form in the pelvis or abdomen, however, and may cause symptoms secondary to mass effect. This case highlights management of an anterectal epidermal inclusion cyst connected to the perineal cyst, mimicking a dumbbell-shaped lesion, found in a male., Case Presentation: This is a unique case of a 21-year-old Caucasian male with a palpable perineal mass, lower extremity hypoesthesia, and constipation who was found to have a complex-shaped cyst on computed tomography and magnetic resonance imaging. This was ultimately managed with a two-stage perineal and transabdominal resection., Clinical Discussion: This case highlights that perineal epidermal inclusion cysts may have pelvic extension, especially in patients with additional new-onset neurologic, gastrointestinal, or urologic symptoms. These symptoms should completely resolve after resection. Additionally, resection is recommended to prevent complications including malignant degeneration and fistulization., Conclusion: This is the first reported case of an anterectal, epidermal inclusion cyst connected to a perineal cyst found in a male. Perineal and pelvic cysts may be synchronous and may be connected through the pudendal canal. These masses can be safely removed via a combined perineal and transabdominal resection. The connecting portion of lesions that have both pelvic and perineal components should be meticulously identified and dissected because even a thin, patent segment - if left unresected - may result in lesion recurrence., (Copyright © 2022. Published by Elsevier Ltd.)

In melanoma metastasis, the role of the AP-2α transcription factor, which is encoded by TFAP2A , is controversial as some findings have suggested tumor suppressor activity while other studies have shown high TFAP2A expression in node-positive melanoma associated with poor prognosis. Here we demonstrate that AP-2α facilitates melanoma metastasis through transcriptional activation of genes within the E2F pathway including EZH2 . A BioID screen found that AP-2α interacts with members of the nucleosome remodeling and deacetylase (NuRD) complex. Loss of AP-2α removed activating chromatin marks in the promoters of EZH2 and other E2F target genes through activation of the NuRD repression complex. In melanoma cells, treatment with tazemetostat, an FDA-approved and highly specific EZH2 inhibitor, substantially reduced anchorage-independent colony formation and demonstrated heritable antimetastatic effects, which were dependent on AP-2α. Single-cell RNA sequencing analysis of a metastatic melanoma mouse model revealed hyperexpansion of Tfap2a High /E2F-activated cell populations in transformed melanoma relative to progenitor melanocyte stem cells. These findings demonstrate that melanoma metastasis is driven by the AP-2α/EZH2 pathway and suggest that AP-2α expression can be used as a biomarker to predict responsiveness to EZH2 inhibitors for the treatment of advanced melanomas. SIGNIFICANCE: AP-2α drives melanoma metastasis by upregulating E2F pathway genes including EZH2 through inhibition of the NuRD repression complex, serving as a biomarker to predict responsiveness to EZH2 inhibitors., (©2021 American Association for Cancer Research.)

Restorative proctocolectomy (RPC) with ileal pouch anal-anastomosis (IPAA) is commonly performed for patients with ulcerative colitis, familial adenomatous polyposis, and selected phenotypes of Crohn's disease (CD). Due to concerns about the effects of surgical complications on pouch functional outcomes, debate remains surrounding when and whether RPC with IPAA should be performed in a staged manner. Particularly debated are the timings of the IPAA, whether it is constructed at time of the proctocolectomy and whether to utilize temporary fecal diversion with a loop ileostomy. RPC with IPAA can be performed in one, two, or three stages, with each stage typically separated by 3-6 months. Proponents of a staged approach argue that poor pouch function, which is often a result of IPAA complications, including leak and infection, can be difficult to overcome and mandate additional, major surgeries, and that staging pouch creation and pairing with a protective ileostomy reduce those complications. However, subjecting patients to multiple surgeries and prolonging their time with an ileostomy present unique risks as well. Surgeons' experience and preference and patient characteristics need to be considered when determining operative planning. Highly selected patients with CD can be considered for RPC with IPAA, although with an acknowledgment of inherently higher pouch failure rates. Understanding the short- and long-term consequences of RPC with IPAA construction can help surgeons determine the appropriate approach.

Activating protein 2 alpha (AP-2α; encoded by TFAP2A ) functions as a tumor suppressor and influences response to therapy in several cancer types. We aimed to characterize regulation of the transcriptome by AP-2α in colon cancer. CRISPR-Cas9 and short hairpin RNA were used to eliminate TFAP2A expression in HCT116 and a panel of colon cancer cell lines. AP-2α target genes were identified with RNA sequencing and chromatin immunoprecipitation sequencing. Effects on cell cycle were characterized in cells synchronized with aphidicolin and analyzed by FACS and Premo FUCCI. Effects on invasion and tumorigenesis were determined by invasion assay, growth of xenografts, and phosphorylated histone H3 (PHH3). Knockout of TFAP2A induced significant alterations in the transcriptome including repression of TGM2 , identified as a primary gene target of AP-2α. Loss of AP-2α delayed progression through S-phase into G 2 -M and decreased phosphorylation of AKT, effects that were mediated through regulation of TGM2 . Buparlisib (BKM120) repressed in vitro invasiveness of HCT116 and a panel of colon cancer cell lines; however, loss of AP-2α induced resistance to buparlisib. Similarly, buparlisib repressed PHH3 and growth of tumor xenografts and increased overall survival of tumor-bearing mice, whereas, loss of AP-2α induced resistance to the effect of PI3K inhibition. Loss of AP-2α in colon cancer leads to prolonged S-phase through altered activation of AKT leading to resistance to the PI3K inhibitor, Buparlisib. The findings demonstrate an important role for AP-2α in regulating progression through the cell cycle and indicates that AP-2α is a marker for response to PI3K inhibitors. IMPLICATIONS: AP-2α regulated cell cycle through the PI3K cascade and activation of AKT mediated through TGM2. AP-2α induced sensitivity to Buparlisib/BKM120, indicating that AP-2α is a biomarker predictive of response to PI3K inhibitors., (©2021 American Association for Cancer Research.)

Intra-abdominal and anorectal abscesses are common pathologies seen in both inpatient and outpatient settings. To decrease morbidity and mortality, early diagnosis and treatment are essential. After adequate drainage via a percutaneous or incisional approach, patients need to be monitored for worsening symptoms or recurrence and evaluated for the underlying condition that may have contributed to abscess formation., Competing Interests: Disclosure D.T. Thompson and J.E. Hrabe have no relevant conflicts of interest or financial ties to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Mammary gland ductal morphogenesis depends on the differentiation of mammary stem cells (MaSCs) into basal and luminal lineages. The AP-2γ transcription factor, encoded by Tfap2c, has a central role in mammary gland development but its effect in mammary lineages and specifically MaSCs is largely unknown. Here, we utilized an inducible, conditional knockout of Tfap2c to elucidate the role of AP-2γ in maintenance and differentiation of MaSCs. Loss of AP-2γ in the basal epithelium profoundly altered the transcriptomes and decreased the number of cells within several clusters of mammary epithelial cells, including adult MaSCs and luminal progenitors. AP-2γ regulated the expression of genes known to be required for mammary development, including Cebpb, Nfkbia, and Rspo1. As a result, AP-2γ-deficient mice exhibited repressed mammary gland ductal outgrowth and inhibition of regenerative capacity. The findings demonstrate that AP-2γ can regulate development of mammary gland structures potentially regulating maintenance and differentiation of multipotent MaSCs., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Helicobacter pylori infection is usually acquired in childhood, but little is known about its natural history in asymptomatic children, primarily due to the paucity of non-invasive diagnostic methods. H. pylori strains harboring cagA and specific alleles of hopQ and vacA are associated with increased risk for gastric cancer. Many studies of H. pylori virulence markers in children have the bias that symptomatic subjects are selected for endoscopy, and these children may harbor the most virulent strains. Our aim is to genotype cagA, hopQ, and vacA alleles in stool DNA samples of healthy Colombian children residing in an area with high incidence of gastric cancer, to avoid selection bias resulting from endoscopy., Methods: H. pylori status of 86 asymptomatic children was assessed by (13) C-urea breath test (UBT) and PCR. H. pylori 16S rRNA, cagA, hopQ, and vacA genes were amplified from stool DNA samples and sequenced., Results: UBT was positive in 69 (80.2%) of 86 children; in stool DNA analysis, 78.3% were positive by 16S rRNA PCR. cagA, vacA, and hopQ were detected in 66.1%, 84.6%, and 72.3% of stool DNA samples from 16S rRNA-positive children. Of the children's DNA samples, which revealed vacA and hopQ alleles, 91.7% showed vacA s1 and 73.7% showed type I hopQ. Type I hopQ alleles were associated with cagA positivity and vacA s1 genotypes (p < 0.0001)., Conclusions: Using stool DNA samples, virulence markers of H. pylori were successfully genotyped in a high percentage of the asymptomatic infected children, revealing a high prevalence of genotypes associated with virulence. Type I hopQ alleles were associated with the presence of cagA and the vacA s1 genotype., (© 2012 Blackwell Publishing Ltd.)

Helicobacter pylori strains display remarkable genetic diversity, and the presence of strains bearing the toxigenic vacA s1 allele, a complete cag pathogenicity island (PAI), cagA alleles containing multiple EPIYA phosphorylation sites, and expressing the BabA adhesin correlates with development of gastroduodenal disease in adults. To better understand the genetic variability present among pediatric strains and its relationship to disease, we characterized H. pylori strains infecting 47 pediatric North American patients. Prevalence of mixed infection was assessed by random amplified polymorphic DNA analysis of multiple H. pylori clones from each patient. Microarray-based comparative genomic hybridization was used to examine the genomic content of the pediatric strains. The cagA and vacA alleles were further characterized by allele-specific PCR. A range of EPIYA motif configurations were observed for the cagA gene, which was present in strains from 22 patients (47%), but only 19 (41%) patients contained a complete cag PAI. Thirty patients (64%) were infected with a strain having the vacA s1 allele, and 28 patients (60%) had the babA gene. The presence of a functional cag PAI was correlated with ulcer disease (P = 0.0095). In spite of declining rates of H. pylori infection in North America, at least 11% of patients had mixed infection. Pediatric strains differ in their spectrum of strain-variable genes and percentage of absent genes in comparison to adult strains. Most children were infected with H. pylori strains lacking the cag PAI, but the presence of a complete cag PAI, in contrast to other virulence markers, was associated with more severe gastroduodenal disease.

We report findings of a survey of 555 women 18-35 years of age living in Northern Manhattan in New York City. The survey was conducted by the Columbia Center for Children's Environmental Health (CCCEH) to learn what community women knew about environmental risks to health and what they did to protect themselves and their families, to validate the findings of focus groups held with community women, and to provide information for planning the Healthy Home, Healthy Child campaign sponsored by CCCEH. Survey findings showed that overall awareness of environmental risks to children's health was high, with more than 95% of respondents identifying lead, household pests, pesticides, environmental tobacco smoke, and drugs as harmful to health. Similarly, more than 95% of respondents reported taking one or more protective actions to reduce these risks, suggesting that these factors significantly concern women living in Northern Manhattan. The reported levels of specific protective actions to reduce these risks, however, varied greatly. In each area of risk the most frequently reported actions were effective ones, but many other important protective actions were rarely mentioned, suggesting that there was room for an educational campaign to teach women new ways to protect their families. Survey respondents and CCCEH scientists differed in the priorities they placed on the importance of key protective actions, confirming earlier focus group findings and suggesting the importance of incorporating community concerns into the planning of environmental campaigns.

Feeding disorders are common in infants and children. Multiple interacting behavioral, anatomic, and functional factors all can impact on the feeding process, making the evaluation and treatment of pediatric disorders complex and challenging. Knowledge of the normal process of feeding and swallowing, a careful history, observation of the patient during a feeding session, and selected tests usually provide an understanding of the underlying cause of feeding difficulties. Treatment of underlying pathology and careful balancing of the risks and benefits of oral feeding underlie the selection of an optimal management strategy.

Several studies have shown that isolates of Edwardsiella ictaluri obtained from infected channel catfish in the southeastern United States harbor two cryptic plasmids, designated pCL1 (5.7 kb) and pCL2 (4.9 kb). These isolates appear to be serologically homogeneous. To extend these studies, we focused our analyses on two isolates of nonictalurid origin. Plasmid analyses of a danio isolate showed that it harbored plasmids which were similar if not identical to pCL1 and pCL2. This strain was also serologically indistinguishable from those isolated from channel catfish. In contrast, a green knife fish (GNF) isolate harbored four plasmids with relative mobilities of 6.0, 5.7, 4.1, and 3.1 kb. Southern blot analyses indicated that only the 5.7- and 4.1-kb plasmids strongly hybridized under high-stringency conditions to probes specific for pCL1 and pCL2, respectively. The GNF isolate showed minimal reactivity when reacted with polyclonal antiserum prepared against a channel catfish isolate. However, polyclonal antiserum to the GNF isolate strongly reacted with the GNF isolate in both surface fluorescence and agglutination reactions. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis analyses of cell lysates showed that the protein banding patterns of the strains compared were similar. However, Western blots of proteinase K-digested cell extracts showed that O antigen of the GNF isolate was antigenically distinct from the O antigen of the other isolates. These studies indicate that there are different serotypes of E. ictaluri and suggest that plasmid and serological analyses of future isolates of E. ictaluri can be used to determine whether structurally distinct strains are emerging in major channel catfish aquaculture areas.

The condition of pneumothorax is re-examined, and a working classification is presented. The present concepts about the mechanisms of production of a pneumothorax are examined and a new approach to the condition is presented. A new system of pneumothorax drainage is described.

A new technique for taking lung, pleural, and pericardial samples, under local anesthesia if required, is described. In the series presented in this article there have been no deaths, and complications which have been discussed are minimal. The experience gained in the use of this technique confirms that it is safe and provides a very high percentage of success in obtaining the required samples.

The visual brightness and albedo of Neptune vary periodically during the 11-year solar cycle with an amplitude of 4%, anticorrelated with the variation of solar ultraviolet output. A seasonal trend in color suggests that Neptune, like Uranus, may have a slightly reddened pole.

Clinical teaching of percussion and auscultation is examined critically, and it is suggested that there is confusion on the subject both in textbooks and in the minds of clinicians and students. Percussion should be viewed more in terms of 'feel' than 'sound', and thus a classification of 'hard', 'intermediate' and 'soft' dullness is introduced. As regards auscultation, a plea is made for differentiation between obstructed and non-obstructed consolidation of lobes, a point recognized by some clinicians, but not enunciated with clarity by teachers. The differences between the clinical findings in obstructive consolidation of the upper and lower lobes are discussed. The importance of distinguishing between tracheal and bronchial breathing is emphasized.

A case report and the management of a 10-year-old girl who had inhaled a foreign body into the right intermediate bronchus at some unknown (but certainly not recent) time previously is given. A stricture at the site of the impaction of the foreign body was found. The excision of the stricture and repair of the bronchus with pericardium is described together with a 3-year follow-up report. The diagnosis and immediate management of foreign bodies in the bronchus are discussed and the importance of differentiating organic and non-organic foreign bodies is stressed. The management of bronchial strictures is discussed as is the result obtained in the above reported case.

Modifications to the intravenous urogram are described. It is suggested that the time has come to rationalise the standard procedure. If an evaluation of the lower urinary tract is required, the voiding films may be modified to provide an intranvenous urodynamogram. If an evaluation of the upper urinary tract is directed at a specific question, then the number of spot-films can often be reduced.