Search

Pati Aji Achdiat,1 Dini Atiyah,1 Fitri Yulianti,1 Endang Sutedja,1 Srie Prihianti Gondokaryono,1 Hermin Aminah Usman,2 Retno Hesty Maharani1 1Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin General Hospital, Bandung, Indonesia; 2Department of Pathology Anatomy, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin General Hospital, Bandung, IndonesiaCorrespondence: Pati Aji Achdiat, Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin General Hospital, Jl. Pasteur No. 38, Bandung, West Java, 40161, Indonesia, Tel/Fax +62222032426 Ext. 3449, Email pati.aji.achdiat@unpad.ac.idIntroduction: Anogenital warts (AGW) are sexually transmitted infections (STIs) caused by the human papillomavirus (HPV), particularly types 6 and 11. The highest incidence of AGW occurs in the age group of 15– 24 years. However, as life expectancy increases, there is a significant rise in the geriatric population worldwide. This demographic shift is directly proportional to the increasing number of STIs cases within the geriatric group.Cases: A case of AGW was reported in a 75-year-old man who had a history of erectile dysfunction medication use and recent sexual contact. During the physical examination, a hyperpigmented plaque with a verrucous surface was observed at the base of the penis. The results of the histopathological examination were consistent with the characteristics of AGW. In addition, HPV genotyping, through polymerase chain reaction (PCR) showed the presence of HPV type 6.Discussion: The aging process leads to a decline in immune function among geriatric individuals, which causes susceptibility to infections, including STIs. Moreover, the geriatric population has a different level of susceptibility to STIs compared to younger individuals. Factors such as physiological changes, decreased sexual function, low awareness of STIs, and having multiple sexual partners further increase the risk of STIs in this age group.Conclusion: Sexual intercourse is an important component of the human life. However, the natural decline in sexual function due to the aging process often occurs with advancing age. As a result, many geriatrics seek various solutions in order to maintain sexual function and activity in old age. Since STIs can occur at any age, early detection and education are essential, particularly for the geriatric population.Keywords: anogenital warts, geriatric, HPV, immunosenescence, sexually transmitted disease

Laila Tsaqilah,1 Hedwika Advina Nastiti,1 Hermin Aminah Usman,2 Erda Avriyanti,1 Hartati Purbo Dharmadji,1 Risa Miliawati Nurul Hidayah1 1Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia; 2Department of Anatomical Pathology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin General Hospital, Bandung, West Java, IndonesiaCorrespondence: Laila Tsaqilah, Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin General Hospital, Jl. Pasteur No. 38, Bandung, West Java, 40161, Indonesia, Tel/Fax +62 822 8447 4849, Email laila.tsaqilah@gmail.comAbstract: Familial Reactive Perforating Collagenosis (FRPC) is a very rare form of benign dermatosis frequently presented during early childhood and not associated with systemic diseases. Less than 50 FRPC patients have been reported in the literature. Due to the limited number of cases, the pathophysiology of this unique entity remains elusive; moreover, no standard treatment has been agreed upon. Here, we report a case of FRPC in a 20-year-old male who was presented with generalized multiple discrete papules covered with central keratotic plugs in all regions of his body, particularly in the facial area, neck, abdominal, and extensor region of the extremities for more than 7 years. Similar symptoms were acknowledged in the patient’s family members. Histopathological analyses identified the crateriform shape invagination in the epidermis filled with inflammatory lymphocytes and basophilic debris and perforated by basophilic collagen bundles from the underlying dermis. Based on the clinical and histopathological findings, the patient was diagnosed with FRPC. He was treated with topical desoximetasone 0.25% cream applied 2– 3 times daily. A follow-up evaluation after 4 weeks revealed a near-complete resolution of skin papules. To our knowledge, this is the first report of FRPC case from Indonesia. Unlike the majority of FRPC patients who had their disease onsets during infancy or early childhood, FRPC skin manifestations in our patient started during the adolescence period. The resolution of skin manifestations after daily application of topical desoximetasone suggests that topical corticosteroids are a potential treatment option for FRPC patients.Keywords: familial reactive perforating collagenosis, benign dermatosis, central keratotic plug, crateriform shape invagination, topical desoximetasone

Pati Aji Achdiat,1 Rita Septharina,1 Rasmia Rowawi,1 Hartati Purbo Dharmadji,1 Diah Puspitosari,1 Hermin Aminah Usman,2 Retno Hesty Maharani1 1Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran–Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia; 2Department of Anatomy Pathology, Faculty of Medicine, Universitas Padjadjaran–Dr. Hasan Sadikin General Hospital, Bandung, West Java, IndonesiaCorrespondence: Pati Aji Achdiat, Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran–Dr. Hasan Sadikin General Hospital, Jl. Pasteur 38, Bandung, West Java, 40161, Indonesia, Tel +6281322750101, Email pati.aji.achdiat@unpad.ac.idAbstract: Extragenital warts caused by HPV types 6 and 11 are rarely reported. However, major risk factors for anogenital warts (AGW) include men who have sex with men (MSM) and Human Immunodeficiency Virus (HIV) infection. The incidence of extragenital warts among these populations has not been reported. This study presented a case report of a 33-year-old male with high-risk sexual behavior who showed symptoms of flesh-colored and hyperpigmentation papules. Furthermore, verrucous surfaces were observed at genital and extragenital. The patient had a history of using the same razor for pubic and armpit hair, bathing with a mesh scrub, and scratching the anal area. The histopathological result showed koilocytes, while polymerase chain reaction (PCR) examination for both genital and extragenital lesions confirmed HPV type 6 and 11. This represented the first reported case describing the incidence of extragenital and AGW caused by HPV types 6 and 11. The transmission of extragenital warts was facilitated through fomites autoinoculation, particularly in the immunocompromised condition induced by HIV, which was common among MSM. Extragenital warty-like lesions were considered as warts caused by HPV type 6/11, in HIV-infected persons, specifically MSM.Keywords: anogenital warts, extragenital warts, human papillomavirus type 6, human papillomavirus type 11, human immunodeficiency virus

Pati Aji Achdiat,1 Muhamad Radyn Haryadi Widjaya,1 Rasmia Rowawi,1 Hermin Aminah Usman,2 Retno Hesty Maharani1 1Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran Dr. Hasan Sadikin Hospital, Bandung, West Java, Indonesia; 2Department of Anatomical Pathology, Faculty of Medicine, Universitas Padjadjaran Dr. Hasan Sadikin Hospital, Bandung, West Java, IndonesiaCorrespondence: Pati Aji Achdiat, Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Jl. Pasteur 38, Bandung, West Java, 40161, Indonesia, Tel +62222032426 ext 3449, Fax +62222032426, Email pati.aji.achdiat@unpad.ac.idAbstract: Vulvar intraepithelial neoplasia (VIN), the precursor lesion of vulvar squamous cell carcinoma (VSCC), may present as pruritic or asymptomatic lichenified plaques surrounded by single or multiple discrete or confluent macules or papules. VIN is divided into high-grade squamous intraepithelial lesion (HSIL), which is human papillomavirus (HPV)-driven, and differentiated VIN (DVIN), which develops independently of HPV. Histopathological examination and HPV genotyping polymerase chain reaction (PCR) tests should be performed to distinguish between HSIL and DVIN. Lichenified plaques surrounded by multiple papules are found not only in VIN but also in vulvar lichen simplex chronicus (LSC). This chronic inflammatory skin disease mostly appears in labia majora and is triggered by sweating, rubbing, and mental stress. IHC staining of p16 and p53 are recommended as the most commonly used biomarkers for VIN in diagnostically challenging cases. IHC staining is also beneficial to confirm the accuracy of the HPV detection technique, as p16-negative staining may also represent a false-positive result. We report a case of the importance of p16 and p53 IHC staining in diagnosing vulvar LSC mimicking VIN with false-positive HPV-66. The patient was previously diagnosed with VIN based on clinical examination. HPV-66 was detected by PCR from a vulvar biopsy sample. Histopathological examination revealed stromal lymphocytic infiltration with non-specific chronic dermatitis; neither atypia nor koilocyte was observed. Both p16 and p53 IHC staining were negative. The patient was diagnosed and treated as vulvar LSC with 10 mg cetirizine tablet, emollient, and 0.1% mometasone furoate cream. Clinical improvement was observed as the lesions became asymptomatic hyperpigmented macules in the 4 weeks of follow-up, without recurrence after 3 years of follow-up. Both p16 and p53 IHC staining might help distinguish HSIL and DVIN mutually and from other vulvar mimics in diagnostically challenging cases.Keywords: immunohistochemical staining, p16, p53, vulvar intraepithelial neoplasia, vulvar lichen simplex chronicus

Laila Tsaqilah,1 Keshia Amalia Mivina Mudia,1 Hermin Aminah Usman,2 Hartati Purbo Dharmadji,1 Risa Miliawati Nurul Hidayah,1 Erda Avriyanti1 1Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran–Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia; 2Department of Anatomical Pathology, Faculty of Medicine, Universitas Padjadjaran–Dr. Hasan Sadikin General Hospital, Bandung, West Java, IndonesiaCorrespondence: Laila Tsaqilah, Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran–Dr. Hasan Sadikin General Hospital, Jl. Pasteur 38, Bandung, West Java, 40161, Indonesia, Tel +6282284474849, Email lailazuardy@gmail.comAbstract: Acquired palmoplantar keratoderma (PPK) is a non-hereditary hyperkeratosis of the palms and soles that is caused by various factors, including chemotherapeutic agents. The purpose of this case report is to present a rare case of acquired PPK caused by the chemotherapeutic agent capecitabine. A 54-year-old female complained of painful erythematous plaques on her palms and soles with history of consuming capecitabine. Physical examination revealed scaly erythematous plaques on the palmoplantar surface and knuckle pads on both hands. Histopathological features showed hyperkeratosis, acanthosis, vasodilatation, and perivascular lymphocytic infiltration. Therefore, the patient was diagnosed with acquired PPK due to capecitabine. The dose of capecitabine was reduced and the patient was administered topical corticosteroid and emollient. Improvement of skin lesions was strongly observed after discontinuation of capecitabine. The underlying cause of PPK should be identified to determine the appropriate treatment. Dose reduction or drug discontinuation is the mainstay therapy for patients with acquired PPK caused by chemotherapeutic agents.Keywords: capecitabine, chemotherapy, palmoplantar keratoderma

Retno Hesty Maharani,1 Tomi Nugraha,1 Endang Sutedja,1 Kartika Ruchiatan,1 Hermin Aminah Usman,2 Pati Aji Achdiat1 1Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin Hospital, Bandung, Indonesia; 2Department of Anatomical Pathology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin Hospital, Bandung, IndonesiaCorrespondence: Pati Aji Achdiat, Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin Hospital, Jl. Pasteur 38, Bandung, West Java, 40161, Indonesia, Tel +62 81322750101, Email pati.aji.achdiat@unpad.ac.idAbstract: Syphilis is a sexually-transmitted disease with various clinical stages. Secondary syphilis manifestations may mimic other skin lesions. Patient co-infected with Human Immunodeficiency Virus (HIV), with CD4 cell counts of 200– 499 cells/mm3, often manifests an atypical cutaneous lesion, which may also occur as nodular or ulcerative lesions. Generalized nodulo-ulcerative lesions without systemic symptoms in secondary syphilis patients with HIV co-infection are rarely reported. A 22-year-old man presented with generalized asymptomatic multiple erythematous papules and plaques with scales, as well as nodular and nodulo-ulcerative lesions on the trunk, both arms, and both legs. His lesions spread progressively without the presence of any prodromal symptoms or adenopathy. He was previously diagnosed with HIV and is currently on antiretroviral medications, with a CD4 cell count of 388 cells/μL. His venereal disease research laboratories (VDRL) result was reactive (titer of 1:256). His Treponema pallidum hemagglutination assay (TPHA) result was also reactive (titer of 1:10,240). A skin biopsy was performed from the nodulo-ulcerative lesion on his back. Hematoxylin-eosin staining revealed a hyperplastic epidermis, a massive influx of plasma cells, and lymphocyte infiltration into the deep dermis, especially in the peri-adnexal, peri-vascular, and peri-muscular regions. The patient was diagnosed with secondary syphilis with HIV co-infection. He had no previous history of drug allergy. A single dose of 2.4 million units of benzathine penicillin G was administered. Almost all the lesions became hyperpigmented macules after two weeks and resolved completely after one month. His VDRL titer declined to 1:32 after three months. The various atypical lesions of secondary syphilis may lead to misdiagnosis and delayed treatment. The presence of multiple asymptomatic nodulo-ulcerative lesion without prodromal symptoms may indicate the presence of secondary syphilis, notably in patients co-infected with HIV. Therefore, knowledge of atypical cutaneous manifestations of secondary syphilis is warranted in order to treat patients accordingly.Keywords: secondary syphilis, human immunodeficiency virus, nodulo-ulcerative lesions

Pati Aji Achdiat,1,2 Yunitasari,1 Hermin Aminah Usman,3 Retno Hesty Maharani1 1Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, West Java, Indonesia; 2Doctoral Study Program, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin General Hospital, Bandung, Indonesia; 3Department of Anatomical Pathology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin General Hospital, Bandung, IndonesiaCorrespondence: Pati Aji Achdiat, Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Jl. Pasteur 38, Bandung, West Java, 40161, Indonesia, Tel +6281225955478 ext. 3449, Fax +62222032426, Email pati.aji.achdiat@unpad.ac.idAbstract: Anogenital warts (AGWs) are globally recognized as the most common sexually transmitted infections (STIs) caused by the human papillomavirus (HPV), particularly types 6 and 11. Meanwhile, immunotherapy is one of the treatments of choice for patients with extensive AGWs. Measles, mumps, and rubella (MMR) vaccine induce the production of various T helper 1 cytokines to elicit immune responses, resulting in the clearance of both treated and untreated warts. This study reported a case of extensive genital and extragenital warts in a 53-year-old male which had occurred for five years, with no pseudo-Koebner phenomenon. The history of MMR vaccination was uncertain but the patient received oral antibiotics for one week, one month before seeking consultation. Physical examination showed extensive verrucous and hyperkeratotic papules, plaques, and nodules in the lower abdomen, pubic, inguinal, genital, and gluteal regions. Acetowhite test results were positive, while polymerase chain reaction (PCR) results were positive for HPV types 6 and 11. The patient received an intralesional injection of 0.5 mL MMR vaccine into the largest warts with a 3-week interval. However, during the one-month follow-up after the third injection, no improvement was observed in either the size or number of warts. Based on the results, several factors must be considered to determine the best candidate for immunotherapy, particularly with MMR vaccine, to achieve an optimal outcome. These factors include the active state of diseases, duration of diseases, as well as a history of sensitization, and broad-spectrum antibiotics.Keywords: anogenital warts, human papillomavirus, immunotherapy, MMR vaccine

Reiva Farah Dwiyana,1 Elisabet Risubekti Lestari,1 Raden Mohamad Rendy Ariezal Effendi,1 Srie Prihianti Gondokaryono,1 Inne Arline Diana,1 Hermin Aminah Usman,2 Kamelia Utami Suhada,1 Rafithia Anandita1 1Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital Bandung, West Java, Indonesia; 2Department of Anatomical Pathology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital Bandung, West Java, IndonesiaCorrespondence: Reiva Farah Dwiyana, Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Jl. Pasteur 38, Bandung, West Java, 40161, Indonesia, Tel +62222032426 ext. 3449, Fax +62222032426, Email reiva@unpad.ac.idIntroduction: Tufted angioma (TA) is a rare benign vascular tumor usually occurring in the first year of life. It may present as reddish papules or purplish red to black plaques. Tender lesions commonly affect the neck, upper trunk, and shoulders. Histologic tufts of capillaries infiltrating the dermis in a “cannon ball” distribution pattern confirm the diagnosis. However, effective treatments for TA are scarce. Pulsed dye laser (PDL) is an alternative therapy for TA, particularly concerning cosmetics and pain relief. This case report demonstrates the effectiveness of PDL as a treatment for TA.Case: We report a 15-year-old girl with five-year history of painful purplish red plaques on her left cheek, neck, chest, left shoulder, and back. Histopathological examination from skin biopsy showed discrete “cannon ball” pattern in the dermis. Laboratory examination revealed normal platelet count and fibrinogen level. Based on these presentations, the diagnosis of TA without complications was made. We treated the lesion using 595-nm PDL with 6.5− 10 J/cm2 fluence of, 1.5 ms pulsed duration, and 5− 7 mm spot size every three weeks. Reductions in redness and pain were seen after four sessions of treatment.Discussion: PDL promotes selective vascular damage with minimal injury to the surrounding skin. Capillary tufts in TA could therefore serve as a target for laser treatment, which may result in fading redness and pain reduction.Conclusion: PDL is effective in reducing redness and pain in TA.Keywords: pulse dye laser, tufted angioma, vascular tumor

Pati Aji Achdiat,1 Syafira Andiani,1 Reti Hindritiani,1 Srie Prihianti Gondokaryono,1 Gempita Nuzuliyah,1 Hermin Aminah Usman,2 Retno Hesty Maharani1 1Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia; 2Department of Anatomical Pathology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin General Hospital, Bandung, IndonesiaCorrespondence: Pati Aji Achdiat, Email pati.aji.achdiat@unpad.ac.idAbstract: Molluscum contagiosum (MC) is a benign papular skin infection caused by Molluscum contagiosum virus (MCV). Over the past 30 years, the incidence of MK has continued to increased association with sexually transmitted infections and human immunodeficiency virus (HIV) infection. The incidence of MC in HIV patients is quite high at 5– 8%. Until now there is no standard therapy used for the treatment of MC in patients with HIV. In HIV patients, anti retro viral therapy (ARV) is the main therapy with several other additional therapies such as cantaridin, chemical peeling agents such as glycolic acid (20– 70%) and trichloroacetic acid (20– 100%), cryosurgery, electrosurgery, incision, lactic acid, laser surgery, podophyllin, retinoic acid, and urea. There have been no studies regarding the administration of topical 20% glycolic acid in MC patients. We report a case of MC in an HIV patient who was treated with 20% topical glycolic acid after failing treatment with topical tretinoin. The diagnosis was made clinically, cytologically, and histopathologically, a white mass was found on compression of the lesion and Henderson-Paterson bodies. The lesions on the face, arms, and legs were given glycolic acid lotion 20% which was applied once a day at night. The lesions started to show responses to the treatment at week 6th as some of the MC papules became hyperpigmented macules. The side effects of therapy that appeared were itching and hyperpigmentation. Topical 20% glycolic acid can be used for MC therapy with minimal side effects, easy to apply and safe.Keywords: molluscum contagiosum, molluscum contagiosum virus, HIV patient, glycolic acid

Endang Sutedja,1 Muhamad Radyn Haryadi Widjaya,1 Hartati Purbo Dharmadji,1 Oki Suwarsa,1 Miranti Pangastuti,1 Hermin Aminah Usman,2 Chaerani Pratiwi Firdaus1 1Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, West Java, Indonesia; 2Department of Anatomical Pathology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, West Java, IndonesiaCorrespondence: Endang Sutedja, Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Jl. Pasteur 38, Bandung, West Java, 40161, Indonesia, Tel +62222032426 ext. 3449, Fax +62222032426, Email endangsutedja@ymail.comAbstract: Lupus erythematosus profundus (LEP) is a rare subset of chronic cutaneous lupus erythematosus (CCLE), with a reported incidence of 1– 3% in all LE cases. The most common cutaneous clinical presentation includes indurated plaques or subcutaneous nodules with an overlying normal skin. The clinical findings range from skin redness to features of CCLE, such as scaling, follicular plugging, and atrophy. Ulceration is rare and occurs in 28% of all LEP cases. We present a case report of LEP with multiple cutaneous ulcers on the right cheek and scalp accompanied by cicatricial alopecia. No other systemic manifestations were noted. Histopathological examination revealed periadipocyte, perivascular, and perivascular infiltration of lymphocytes, eosinophils, and plasma cells, supporting the diagnosis of LEP. The topical treatments given to the patient were sunscreen, 2% mupirocin cream, and wound dressing with dialkyl carbamoyl chloride (DACC). The patient was also treated systemically with oral corticosteroids and hydroxychloroquine. Clinical improvements were observed in the 3rd month of follow-up, and ulcer healing resulted in atrophic scars and fading erythematous macules. LEP is seldom associated with systemic or discoid lupus erythematosus. This occurs twice as frequently as a distinct entity does. Diagnosis accuracy plays an important role in determining the appropriate wound care, topical, and systemic treatments for LEP patients with multiple overlying cutaneous ulcerations.Keywords: cutaneous ulcerations, lupus erythematosus profundus, multiple, rare case

Amira Shafuria,1 Irna Sufiawati,2 Hermin Aminah Usman3 1Oral Medicine Residency Program, Faculty of Dentistry, Padjadjaran University, Bandung, Indonesia; 2Department of Oral Medicine, Faculty of Dentistry, Padjadjaran University, Bandung, Indonesia; 3Department of Anatomical Pathology, Faculty of Medicine, Padjadjaran University/Dr. Hasan Sadikin General Hospital, Bandung, IndonesiaCorrespondence: Irna Sufiawati, Email irna.sufiawati@fkg.unpad.ac.idIntroduction: Dermatitis herpetiformis (DH) is an autoimmune vesiculobullous disease associated with celiac enteropathy. The clinical manifestation of DH is the occurrence of a papulovesicular rash on the skin. Oral mucosal involvement in DH is very rare. This study aimed to describe the impact of COVID-19 on the acute exacerbation of oral dermatitis herpetiformis.Case Report: A 74-year-old woman was referred to the Oral Medicine Department with a chief complaint of the blisters on the skin for a week and ulcers in the oral cavity appeared two days ago. Extraoral examination revealed crusts on the neck and extremities. The lips appeared dry and desquamative. Intraoral examination revealed erosive lesions covered with a white-yellowish plaques on the right and left sides of the buccal mucosa, an ulcer with a diameter of 0.5 cm, and purpura hemorrhagic on left buccal mucosa and right lateral border of the tongue. Histopathological examination of the skin lesion revealed a subepithelial blister with eosinophils and neutrophil cells. The definitive diagnosis of dermatitis herpetiformis was made. She was given 5 mg intravenous dexamethasone, cetirizine 10 mg, and clindamycin 300 mg by the dermatologist. We gave hyaluronic acid 0.025% mouthwash for oral ulcers and petroleum jelly for the lips. The oral lesions had significant improvement after 4 weeks of treatment. Two months later, the patient experienced acute exacerbation after being infected with COVID-19 (anti-SARS-CoV-2 IgG S-RBD > 40,000 AU/mL). The oral lesions healed after a month of treatment.Conclusion: COVID-19 can trigger the acute exacerbation of dermatitis herpetiformis. SARS-CoV-2 causes an immune dysregulation and hypersensitivity reaction.Keywords: COVID-19, dermatitis herpetiformis, geriatric patient

Fauzan Ali Zainal Abidin, Hermin Aminah Usman, Sri Suryanti, Bethy S Hernowo Department of Anatomical Pathology, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, IndonesiaCorrespondence: Hermin Aminah UsmanDepartment of Anatomical Pathology, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Jl Pasteur No. 39, Bandung, West Java, 40161, IndonesiaTel +62 22-2031447Fax +62 22-2551126Email hermin@unpad.ac.idBackground: Acral melanoma (AM) is a malignancy that originates from melanocytes, located in an anatomical area without sun exposure, aggressive, resistant to chemotherapy, and quickly metastasize. The invasion capability of tumor cells is the main factor for metastasis in malignancy. E-cadherin is a marker of tumor progressivity that has an important role in the process of invasion. The responsibility of E-cadherin in the invasion process of AM is not well known. CD103 is an immune component found in the tumor microenvironment that contributes to melanoma progression control, whereas E-cadherin is the ligand for CD103.Purpose: The objective of this research was to see if there was an association between E-cadherin and CD103 immunoexpression and the thickness of invasion in AM.Materials and Methods: This is observational cross-sectional research. Formalin-fixed paraffin-embedded (FFPE) acral melanoma tissue samples were collected during 2014– 2020 at the Department of Anatomic Pathology, Dr. Hasan Sadikin Hospital, Bandung. A total of 40 samples were collected, including 20 cases of invasive melanoma less than 4 mm thickness and 20 cases of invasive melanoma greater than 4 mm thickness. All samples were immunostained with E-cadherin and CD103. Chi-Square test was used to examine the association concerning E-cadherin and CD103 with the thickness of invasion, respectively. The p-value of 0.05 was chosen as the significance level.Results: This study showed an insignificant association between E-cadherin immunoexpression and the thickness of invasion on AM (p = 0.4272). CD103 immunoexpression had a significant association with the thickness of invasion on AM (p = 0.0001).Conclusion: The findings revealed that CD103 in AM is associated with the thickness of invasion, and it may play important functions throughout the invasion process despite the uninvolvement of E-cadherin.Keywords: CD103, E-cadherin, acral melanoma, invasion

Nastassa Gipsyianti, Afiati Aziz, Bethy S Hernowo, Hermin A Usman Department of Pathology Anatomy, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, IndonesiaCorrespondence: Hermin A UsmanDepartment of Pathology Anatomy, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, IndonesiaEmail hermin.seroja@gmail.comIntroduction: Acral melanoma (AM) has a poor prognosis since it is easily metastatic and resistant to chemo and immunotherapy. Cyclooxygenase-2 (COX-2) is an enzyme that plays a role in the carcinogenesis process. The increased expression of COX-2 has an impact on increasing levels of Myeloid-Derived Suppressor Cell (MDSC), which is a key regulator of immune. The increase in MDSC produces Transforming Growth Factor β 1 (TGF-β 1), which will suppress Natural Killer (NK) cells and Dendritic Cells (DC) function so that tumor cells are spared from the immune systems and are easier to invade surrounding tissues.Purpose: This study aimed to determine the role of COX-2 and TGF-β 1 on the depth of invasion on AM.Materials and Methods: This study was a cross-sectional observational study on 40 paraffin blocks of AM cases during 2014– 2019 in the Department of Pathology Anatomy, Faculty of Medicine, Dr. Hasan Sadikin General Hospital, Bandung. The depth of invasion of all samples was measured by dotSlide imaging software and the immunohistochemical staining of COX-2 and TGF-β 1 was performed. The association between COX-2 and TGF-β 1 expression and AM depth of invasion were analyzed using Mann Whitney.Results: The result showed a significant association between COX-2 and TGF-β 1 expression and depth of invasion on AM. COX-2 expression had a significant association with TGF-β 1 expression (0.0001). Through multivariate analysis, it was found that COX-2 had the greatest association with the depth of invasion (p=0.0001).Conclusion: The findings showed that increasing expression of COX-2 in AM is associated with the depth of invasion by increasing TGF-β 1 and it might play important roles during the invasion process of AM.Keywords: acral melanoma, COX-2, depth of invasion, TGF-β 1

Background: Uterine corpus cancer is primarily a disease of postmenopausal women. It is worthwhile to look at the histopathologic types of uterine corpus cancers in an environment where these types of cancers are relatively uncommon. Objective: To determine the histo-pathological types of uterine corpus cancers seen in Maiduguri, North–eastern Nigeria. Methods: This was a twenty year retrospective review of histo-pathological types of uterine corpus cancers seen from January 1989 to December 2008. Results: Of the 43 cases of uterine corpus cancers, 29(67.4%) were endometriod carcinomas, 7(16.3%) were special variant carcinomas, 4(9.3%) were sarcomas, 2 (4.7%) were metastasis from the cervix and 1(2.3%) was a mixed Mullerian tumour. The mean age was 51.1+ 10.6. The peak age specific incidence was 45-54years. Conclusion: The peak age specific incidence of uterine corpus cancer in Maiduguri is lower compared to that in western countries. Leiomyosarcoma (LMS) was found to be higher in Maiduguri than reports from the western world.

Abstract Background Live donor kidney transplantation is the preferred kidney replacement therapy for eligible patients but requires thorough donor evaluation to minimise risks. Contemporary guidelines recommend split kidney function measurement in living donors only when there is a significant kidney size discrepancy, yet the evidence for this is poor, and practice varies nationally. This study evaluates the efficacy of CT-derived kidney metrics in detecting significant functional asymmetry. Methods We conducted a retrospective cohort analysis of 123 prospective living kidney donors at a regional transplant centre from June 2011 to October 2014, utilising CT to determine kidney and cortical volumes and lengths. Asymmetric kidney function (AKF), defined by > 10% function difference on DMSA scans, was correlated with CT measurements to calculate the diagnostic accuracy of current guidelines. Results Among the prospective donors, the median age was 42 years, and 59.3% were female. The median split kidney function difference was 4%, with 25 individuals exhibiting > 10% AKF. Kidney length discrepancy proved to be a poor indicator of AKF (sensitivity: 28%, specificity: 84%). While negative predictive values for cortical and kidney volumes were high (96% and 93%, respectively), sensitivity was low, and specificity and positive predictive value did not meet satisfactory thresholds. Conclusions CT-derived metrics of kidney length, cortical, and total volume show limited sensitivity and specificity in identifying significant AKF. These findings provide evidence to support revised guideline development in the assessment of living kidney donors.

Abstract Introduction Despite the widespread use of pre-exposure prophylaxis (PrEP) in preventing human immunodeficiency virus (HIV) transmission, scant information on HIV drug resistance mutations (DRMs) has been gathered over the past decade. This review aimed to estimate the pooled prevalence of pre-exposure prophylaxis and its two-way impact on DRM. Methods We systematically reviewed studies on DRM in pre-exposure prophylaxis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 guidelines. PubMed, Cochrane, and SAGE databases were searched for English-language primary studies published between January 2001 and December 2023. The initial search was conducted on 9 August 2021 and was updated through 31 December 2023 to ensure the inclusion of the most recent findings. The registration number for this protocol review was CRD42022356061. Results A total of 26,367 participants and 562 seroconversion cases across 12 studies were included in this review. The pooled prevalence estimate for all mutations was 6.47% (95% Confidence Interval-CI 3.65–9.93), while Tenofovir Disoproxil Fumarate/Emtricitabine-associated drug resistance mutation prevalence was 1.52% (95% CI 0.23–3.60) in the pre-exposure prophylaxis arm after enrolment. A subgroup analysis, based on the study population, showed the prevalence in the heterosexual and men who have sex with men (MSM) groups was 5.53% (95% CI 2.55–9.40) and 7.47% (95% CI 3.80–12.11), respectively. Notably, there was no significant difference in the incidence of DRM between the pre-exposure prophylaxis and placebo groups (log-OR = 0.99, 95% CI −0.20 to 2.18, I2 = 0%; p = 0.10). Discussion Given the constrained prevalence of DRM, the World Health Organization (WHO) advocates the extensive adoption of pre-exposure prophylaxis. Our study demonstrated no increased risk of DRM with pre-exposure prophylaxis (p > 0.05), which is consistent with these settings. These findings align with the previous meta-analysis, which reported a 3.14-fold higher risk in the pre-exposure prophylaxis group than the placebo group, although the observed difference did not reach statistical significance (p = 0.21). Conclusions Despite the low prevalence of DRM, pre-exposure prophylaxis did not significantly increase the risk of DRM compared to placebo. However, long-term observation is required to determine further disadvantages of extensive pre-exposure prophylaxis use. PROSPERO Number: CRD42022356061.

Abstract Recently, the CMS and ATLAS collaborations have announced the results for H → Z[→ ℓ + ℓ − ]γ with ℓ = e or μ [1, 2], where H → Zγ is a sub-process of H → ℓ + ℓ − γ. This semi-leptonic Higgs decay gets both resonant and non-resonant contributions from the loop-induced H → Z[→ ℓ + ℓ − ]γ. To probe further features coming from these contributions to H → ℓ + ℓ − γ, we argue that the polarization of the final state leptons is also an important parameter. We show that the interference of resonant and non-resonant contributions, which is negligible in the case of unpolarized leptons, plays a significant role when considering the polarization of the final state lepton. For this purpose, we have calculated the polarized decay rates and the longitudinal (P L ), normal (P N ), and transverse (P T ) polarization asymmetries. We find that these asymmetries purely come from the loop contributions and are helpful to further investigate the resonant and non-resonant nature of H → Z[→ ℓ + ℓ − ]γ decay. We observe that for ℓ = e, μ, the longitudinal decay rate is highly suppressed around m ℓℓ ≈ 60 GeV when the final lepton spin is − 1 2 $$ -\frac{1}{2} $$ , dramatically increasing the corresponding lepton polarization asymmetries. Furthermore, we analyze another observable, the ratio of decay rates R i ± ll ′ $$ {R}_{i\pm}^{{\mathcal{ll}}^{\prime }} $$ , where ℓ and ℓ ′ refer to different final state lepton generations. Precise measurements of these observables at the HL-LHC and the planned e + e − collider can provide fertile ground to test not only the SM but also to examine the signatures of possible NP beyond the SM.

Usman Hamid is the Chairperson of the Public Virtue Institute and Director of Amnesty International Indonesia. He is also a lecturer at the Indonesia Jentera School of Law, a human rights lawyer, and a member of the expert council at the Indonesian Bar Association (PERADI-RBA). In 1998, as a student activist at Trisakti University, he became involved in protests that contributed to the fall of the Suharto regime. He subsequently became the coordinator of KontraS, the Commission for Missing Persons and Victims of Violence. In 2004, he was appointed to the Presidential Fact-Finding Team that investigated the murder of prominent human rights defender Munir Said Thalib. In 2011, he was appointed to the Presidential Unit for the Supervision of Development, where he reviewed Indonesia’s National Human Rights Action Plan for 2011–2014. This commentary reflects on the unmet expectations of human rights improvements during President Jokowi's two terms in Indonesia. Written from his perspective of a long-time human rights activist, Usman Hamid critiques Jokowi's failure to address key human rights issues, including past violations, minority protections, and civil liberties, despite Jokowis early promises. The author combines personal experiences with an analysis of Jokowi's political compromises and their impact on Indonesia's declining human rights landscape.

BackgroundAccurate diagnosis of enteric fever is challenging, particularly in low- and middle-income countries, due to the overlap of clinical and laboratory features with other pathogens. To better understand the difficulties in enteric fever diagnosis, we evaluated the characteristics of patients clinically diagnosed with enteric fever and the real-world performance of TUBEX TF, one of the most used tests in Indonesia.Methodology/principal findingsPatients were recruited through the AFIRE (Etiology of Acute Febrile Illness Requiring Hospitalization) study at eight Indonesian hospitals. Blood culture was performed for all patients, and TUBEX TF was performed for suspected enteric cases. Salmonella PCR and ELISA tests were performed at a reference lab. Sensitivity and specificity of TUBEX TF and IgM and IgG anti-S. Typhi ELISA were determined. Of 301 patients clinically diagnosed with enteric fever, 50 (16.6%) were confirmed by blood culture and/or PCR. Confirmed cases were mostly school-aged children presenting with fever, anorexia, dizziness and/or abdominal pain with normal leukocyte count or leukopenia. TUBEX TF demonstrated a sensitivity of 97.6% to 70.7% and specificity of 38.3% to 67.2% at cutoffs of 4 and 6, respectively. Acute IgG demonstrated the best sensitivity and specificity, at 90.7% and 82.7%, respectively, and the best ROC characteristics.Conclusions/significanceA substantial proportion of enteric fever was misdiagnosed at all study hospitals, likely due to the overlap of clinical characteristics and lab parameters with those of other common pathogens. The TUBEX TF rapid serological assay demonstrated suboptimal performance in our setting and tended to over-diagnose enteric fever. The role of IgG from acute specimens for identification of enteric fever cases merits additional consideration.

The extant literature lavishes its focus on understanding Russia’s motivation for starting a war against Ukraine and on the broader question of the role of technology in determining the outcome of war. This article, however, undertakes a comprehensive examination of the relatively ignored yet important aspect of adapting military strategy during the war through Russian experience. It demonstrates that the Russian strategists have shown adequate appreciation for the principle of adaptation in formulating military strategy. To this effect, it identifies and explains three distinct sequential adaptations in the Russian military strategy during the ongoing Ukrainian war. The analysis, conducted with thoroughness and rigor, demonstrates that the Russian armed forces made a relatively quicker transition from the show of force to offense to defense. It also delves into the factors that drove these adaptations. This research has implications for both theory and policy. On the theoretical side, it reinforces the organic relationship between strategy and war. On the policy side, it highlights the importance of adapting military strategy to contain and limit the scope of war.

The complex linguistic characteristics and limited resources present sentiment analysis in Roman Urdu as a unique challenge, necessitating the development of accurate NLP models. In this study, we investigate the performance of prominent ensemble methods on two diverse datasets of UCL and IMDB movie reviews with Roman Urdu and English dialects, respectively. We perform a comparative examination to assess the effectiveness of ensemble techniques including stacking, bagging, random subspace, and boosting, optimized through grid search. The ensemble techniques employ four base learners (Support Vector Machine, Random Forest, Logistic Regression, and Naive Bayes) for sentiment classification. The experiment analysis focuses on different N-gram feature sets (unigrams, bigrams, and trigrams), Chi-square feature selection, and text representation schemes (Bag of Words and TF-IDF). Our empirical findings underscore the superiority of stacking across both datasets, achieving high accuracies and F1-scores: 80.30% and 81.76% on the UCL dataset, and 90.92% and 91.12% on the IMDB datasets, respectively. The proposed approach has significant performance compared to baseline approaches on the relevant tasks and improves the accuracy up to 7% on the UCL dataset.

Recent advances in Generative Adversarial Networks (GANs) have produced synthetic images with high visual fidelity, making them nearly indistinguishable from human-created images. These synthetic images referred to as deepfakes, have become a major source of misinformation due to social media. Technology is advancing rapidly, so reliable methods for distinguishing real from fake images are needed. The current detection mechanisms require image forensics tools such as error level analysis (ELA), and clone detection to detect manipulated images. These approaches are limited because they require forensics expertise to use, are manual in application nature, and are unscalable, creating a need for a framework for a scalable tool that experts and non-experts can use to combat the spread of manipulated images and preserve digital visual information authenticity. We approach this problem with a multi-model ensemble framework using the transfer learning method to effectively detect fake images. The proposed approach named Multi-Model GAN Guard (MMGANGuard)integrates four models into an ensemble framework to identify GAN-generated image characteristics to improve deepfake detection. The Gram-Net architecture, ResNet50V2, and DenseNet201 models are used with co-occurrence matrices using transfer learning for MMGANGuard. Through comprehensive experiments, the proposed model demonstrates promising results in detecting the deepfake with high accuracy on the StyleGAN dataset. For automated detection of deepfake-generated images, the proposed model exceeded 97% accuracy, 98.5% TPR, 98.4% TPR, and 95.6% TPR in these evaluations, eliminating the need for manual assessment which is promising for future research in this domain.

Recommender systems are crucial in today’s digital world, by enhancing user engagement experience in digital ecosystems. Internet of things (IoT) have huge potential to generate dynamic and real time data. The data generated through IoT are being utilized to extract dynamic context of the user. Integrating recommender systems with context-aware (IoT data) and cross-domain (Knowledge Transfer) capabilities have the capacity to further enhance the accuracy and relevance of recommendation systems. However, recommender systems struggle with the cold start problem, where non-availability of data hinders to make effective recommendations for new users. Therefore, IoT-enabled Context-Aware Cross-Domain Recommender Systems may employ latent user profiling to provide personalized and exceedingly relevant recommendations across domains. The proposed system, named Knowledge Transfer Cross-Domain User Latent Factors (KT-CDULF), creates a user profile that spans multiple data domains, capturing a wide range of user behavior on all domains. The KT-CDULF captures the combined knowledge across domains to make recommendations even with limited user data, i.e. cold start problem. Domain-independent factors, and context can be used across domains to make relevant recommendations. The effectiveness of a recommender system depends on the density of the ratings in the data. To address this, KT-CDULF used two benchmark datasets to create user profiles and an item-rating matrix with additional context extracted from IoT generated dataset. KT-CDULF is evaluated and compared it with state-of-the-art models for recommender systems and achieves an accuracy of 98%, demonstrating the benefits of transferring knowledge containing context across data domains in recommender systems.

Computer-aided decision support systems (DSSs) are becoming popular in a variety of professions. Notably, medical DSSs assist healthcare professionals (decision makers) choose the optimal course of action (decisions) while treating patients. Such systems help decision-makers in situations when there is uncertainty in manual decisions due to lack of information or expertise. Choosing a suitable learning algorithm in a DSS is essential and affects its performance. Among machine learning (ML) algorithms, artificial neural networks (ANNs) are considered the most suitable framework for many classification tasks. In healthcare, an ML-based prediction system/DSS employs data (genetic profile or clinical characteristics) and learning algorithms to forecast target values, which may give promising results. However, improving prediction accuracy is a crucial step in making informed decisions. One can apply various preprocessing methods (cross validation, feature selection, bagging, boosting, etc.) to achieve this. For complex classification tasks like cancer, decision-makers can utilize the hybridization of classifiers to increase prediction accuracy. The presented study investigates the possibilities of improvements in the design of hybridized systems for DSSs to assist healthcare professionals in robust decision-making before, during, and after cancer diagnosis. Since the network weights and the activation functions are the two crucial elements in the learning process of an ANN, this study is organized to investigates the improvement in the hybrid system by selecting suitable features from gene expression microarray data and using these features to compute the more realistic initial weights instead of using random guesses as initial weights for ANN. The use of the proposed framework gives promising results (upto 6.67% gain in accuracy when compared to previous study (Table-5) while 10.43% increase in accuracy when compared to conventional ML classifiers (Table-4).

The classification of large-scale textual dataset is associated with a huge number of instances and millions of features which must be discriminated between large numbers of categories. The task requires the utilization of a defined hierarchy structure and tools that automatically classify instances within the hierarchy known as Large Scale Hierarchical Text Classification (LSHTC). Predicting the labels of instances by the employed classifiers is challenging due to the high number of features. Furthermore, the existing Dimensional Reduction (DR) approaches in cooperation with the LSHTC framework are still quite inefficient. In such a problem, an effective Hierarchical Dimensional Reduction approach can be advantageous in improving the performance of the LSHTC. Therefore, in this paper, we enhance the performance of LSHTC by proposing a Multi-stage Hierarchical Dimensional Reduction (MHDR) approach based on Modified Feature Hashing (MFH) and Hierarchical Bi-Filtering (HBF) method. In addition to alleviating bad collision and result discrepancy, experimental results show that the proposed approach has achieve the best performance in terms of micro-f1 and macro-f1 by recording average scores of 58.47% and 54.77% using TD-SVM, and average scores of 51.14% and 48.70% using TD-LR, respectively. The method also achieved 11% speed-up than the approaches compared.

Sarcasm has a significant role in human communication especially on social media platforms where users express their sentiments through humor, satire, and criticism. The identification of sarcasm is crucial in comprehending the sentiment and the communication context on platforms like Twitter. This ambiguous nature of the expression of content presents the detection of sarcasm as a considerable challenge in natural language processing (NLP). The importance and challenges increase further, especially in languages like Urdu where resources for NLP are limited. The traditional rule-based approaches lack the desired performance because of the subtle and context-based nature of sarcasm. However, the recent advancements in NLP, particularly the transformer architecture-based large language models (LLMs) like BERT offer promising solutions. In this research, we have utilized a newly created Urdu sarcasm dataset comprising 12,910 tweets manually re-annotated into sarcastic and non-sarcastic classes. These tweets were derived from the public Urdu tweet dataset consisting of 19,995 tweets. We have established baseline results using deep learning classifiers comprising CNN, LSTM, GRU, BiLSTM, and CNN-LSTM. To comprehensively capture the contextual information, we propose a novel hybrid model architecture that integrates multilingual BERT (mBERT) embeddings with BiLSTM and multi-head attention (MHA) for Urdu sarcasm. The proposed mBERT-BiLSTM-MHA model demonstrates superior performance by achieving an accuracy of 79.51% and an F1 score of 80.04%, outperforming deep learning classifiers trained with fastText word embeddings.

Industrial Internet of Things (IIoT) applications consist of resource constrained interconnected devices that make them vulnerable to data leak and integrity violation challenges. The mobility, dynamism, and complex structure of the network further make this issue more challenging. To control the information flow in such environments, access control is critical to make collaboration and communication safe. To deal with these challenges, recent studies employ attribute-based access control on top of blockchain technology. However, the attribute-based access control frameworks suffer due to high computational overhead. In this paper, we propose an improved role-based access control framework using hyperledger blockchain to deal with IIoT requirements with less computational overhead making the information control process more efficient and real-time. The proposed framework leverages a layered architecture of chaincodes to implement the improved access control framework that handles the permission delegation and conflict management to deal with the dynamism of the IIoT network. The system uses a Policy Contract, Device Contract, and Access Contract to manage the workflow of the whole access control process. Each chaincode in the proposed framework is isolated in terms of its responsibilities to make the design low coupled. The integration of improved access control with blockchain enables the proposed framework to provide a highly scalable solution, tamper-proof, and flexible to manage conflicting scenarios. The proposed system outperforms the recent studies significantly in computational overhead in extensive simulation results. To verify the scalability and efficiency, the proposed is evaluated against a large number of concurrent virtual clients in simulation and statistical analysis proves that the proposed system is promising for further research in this domain.

In histopathological image analysis, the feature extraction task for classification proves to be demanding. This difficulty arises from the assortment of histological features appropriate for individual problems and the intricate presence of diverse geometric structures. The method proposed in this study leverages dictionary learning and sparse coding techniques to create priors tailored to specific targets, which is essential for classification purposes. Our approach introduces Penalized Sequential Discriminative Dictionary Learning (PSDDL), designed to integrate histopathological image features by acquiring structured, class-specific dictionaries. Initially, PSDDL constructs a dictionary from the input data, incorporating label information for each class. Subsequently, the proposed algorithm introduces a penalty and regularization term to amplify the efficacy of the acquired dictionary. Furthermore, the proposed method also tackles the class imbalance in the dataset by leveraging dictionary learning. Mainly, under-sampling is performed on the dataset, and the number of samples of fewer classes is kept for all categories and passed to the dictionary learning algorithm. Extensive experimental results highlight a notable enhancement in classification performance. The proposed structured discriminative dictionary learning technique consistently produces improved accuracies compared to other contemporary methods for classifying the BreakHis breast cancer dataset. Integrating class-specific information into the process of dictionary learning paves the way for enriching the interpretive capabilities of machine learning models while delving deeper into our comprehension of the complex and intricate structures inherent in biological tissues.

Background: Despite the availability of various effective antiretroviral (ARV) drugs, human immunodeficiency virus (HIV) infection has come with HIV drug resistance (HIVDR), which compromises its effectiveness in reducing HIV-related morbidity, mortality, and transmission. The emergence of transmitted (TDR) and acquired HIVDR (ADR) among antiretroviral therapy (ART)-naïve and experienced individuals have been reported in several Indonesian regions. Therefore, continuous HIVDR surveillance is needed in Indonesia, especially in Surabaya, which is identified as having the highest prevalence of HIV infection in East Java; thus, this study aimed to identify the emergence of TDR and ADR among people living with HIV/acquired immune deficiency syndrome (AIDS) (PLWHA). Methods: Fifty-eight PLWHA infected with HIV type 1 (HIV-1), comprising 21 and 37 ART-naïve and experienced individuals were enrolled in this study, respectively. Blood samples collected from study participants were subjected to genotypic analysis, mainly towards the pol gene encoding protease (PR gene) and reverse transcriptase (RT gene) of HIV-1. Results: Seventeen PR and 21 RT genes were successfully amplified and sequenced from 29 samples. HIV-1 subtyping revealed CRF01_AE as the most dominant subtype (24/29; 82.76%), followed by subtype B (3/29; 10.34%). Uncommon subtypes, including subtype D and a recombinant containing subtypes B and G genomic fragments, were also identified. TDR for PR inhibitors was not detected; however, TDR and ADR for RT inhibitors were identified in 11.11% and 41.67% of samples, respectively. Two amino acid insertions at position 69 of the RT gene (69ins), a previously never-reported mutation in Indonesia, were identified in this study. Conclusion: Both TDR and ADR have emerged among PLWHA residing in Surabaya, East Java, Indonesia. Uncommon drug-resistance mutations and subtypes were identified in this study. These situations might hamper ART efficacy and treatment success. Continuous surveillance of HIVDR is necessary to monitor both TDR and ADR in Indonesia.

Abstract Background BRCA1 and BRCA2 (BRCA1/2) are the most frequently investigated genes among Caucasian pancreatic cancer patients, whereas limited reports are available among Asians. We aimed to investigate the prevalence of BRCA1/2 germline variants in Pakistani pancreatic cancer patients. Methods One hundred and fifty unselected and prospectively enrolled pancreatic cancer patients were comprehensively screened for BRCA1/2 germline variants using denaturing high-performance liquid chromatography and high-resolution melting analyses, followed by DNA sequencing of the variant fragments. The novel variants were analyzed for their pathogenic effect using in-silico tools. Potentially functional variants were further screened in 200 cancer-free controls. Results Protein truncating variant was detected in BRCA2 only, with a prevalence of 0.7% (1/150). A frameshift BRCA2 variant (p.Asp946Ilefs*14) was identified in a 71-year-old male patient of Pathan ethnicity, with a family history of abdominal cancer. Additionally, we found a novel variant in BRCA2 (p.Glu2650Gln), two previously reported variants in BRCA1 (p.Thr293Ser) and BRCA2 (p.Ile2296Leu) and a recurrent nonsense variant in BRCA2 (p.Lys3326Ter). These variants were classified as variants of uncertain significance (VUS). It is noteworthy that none of these VUS carriers had a family history of pancreatic or other cancers. Conclusions In this first study, BRCA1/2 pathogenic variant is identified with a low frequency in pancreatic cancer patients from Pakistan. Comprehensive multigene panel testing is recommended in the Pakistani pancreatic cancer patients to enhance genetic understanding in this population.

Objective: To understand how the acute exacerbations of chronic obstructive pulmonary disease (COPD) can lead to coagulation dysfunctions causing hemostatic abnormalities (prolonged prothrombin time, slightly longer activated partial thromboplastin time, higher fibrinogen levels, higher D-dimer levels, and slightly lower platelet counts). Study Design: Comparative cross-sectional. Place and Duration of Study: The study was conducted at the Department of Internal Medicine Pak Emirates Military Hospital (PEMH) Rawalpindi, Pakistan during the period of July 2023 to December 2023. Methods: The current study utilized patients with a confirmed diagnosis of Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) who were hospitalized in the respiratory care unit and were above 50 years of age. A total of 200 patients were accessed including their demographic characteristics (age, gender, residence, and job), clinical parameters (spirometry results (Forced expiratory volume in one second/Functional vital capacity ratio), complete blood counts, fibrinogen, prothrombin, activated partial thromboplastin time, D-dimers and arterial blood gas analysis. The intricate relationship between coagulation dysfunction and acute exacerbations of chronic obstructive pulmonary disease was analyzed using SPSS 26. Results: The results obtained that; patients with acute exacerbation of chronic obstructive pulmonary disease had prolonged prothrombin time (13.5 ± 1.2 seconds, P < 0.001) slightly longer aPTT (32.1 ± 2.5 seconds, P = 0.014), along with higher fibrinogen levels (350.2 ± 45.8 mg/dL, P < 0.001) and D-dimer levels (550.4 ± 120.3 ng/mL, P = 0.002), as compared to patients with stable chronic obstructive pulmonary disease. The platelet counts of Acute exacerbation of chronic obstructive pulmonary disease patients obtained were slightly lower (260.3 ± 45.4x10^3/μL, P = 0.009) compared to stable chronic obstructive pulmonary disease patients. Furthermore, results provided that coagulation dysfunction was significantly associated with infection, hypercapnia, and acute exacerbation of chronic obstructive pulmonary disease. The prevalence of coagulation dysfunction markers was higher among patients with acute exacerbation of chronic obstructive pulmonary disease. Conclusion: Coagulation dysfunction and its associated risk factors are higher in patients with acute exacerbation of chronic obstructive pulmonary disease and are elevated with increased exposure to air pollution.

Severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) ribonucleic acid (RNA) shedding is an important parameter for determining the optimal length of isolation period required for coronavirus disease 2019 (COVID-19) patients. However, the clinical (i.e., patient and disease) characteristics that could influence this parameter have yet to be determined. In this study, we aim to explore the potential associations between several clinical features and the duration of SARS-CoV-2 RNA shedding in patients hospitalized with COVID-19. A retrospective cohort study involving 162 patients hospitalized for COVID-19 in a tertiary referral teaching hospital in Indonesia was performed from June to December 2021. Patients were grouped based on the mean duration of viral shedding and were compared based on several clinical characteristics (e.g., age, sex, comorbidities, COVID-19 symptoms, severity, and therapies). Subsequently, clinical factors potentially associated with the duration of SARS-CoV-2 RNA shedding were further assessed using multivariate logistic regression analysis. As a result, the mean duration of SARS-CoV-2 RNA shedding was found to be 13 ± 8.44 days. In patients with diabetes mellitus (without chronic complications) or hypertension, the duration of viral shedding was significantly prolonged (≥13 days; p = 0.001 and p = 0.029, respectively). Furthermore, patients with dyspnea displayed viral shedding for longer durations (p = 0.011). The multivariate logistic regression analysis reveals that independent risk factors associated with the duration of SARS-CoV-2 RNA shedding include disease severity (adjusted odds ratio [aOR] = 2.94; 95% CI = 1.36–6.44), bilateral lung infiltrates (aOR = 2.79; 95% CI = 1.14–6.84), diabetes mellitus (aOR = 2.17; 95% CI = 1.02–4.63), and antibiotic treatment (aOR = 3.66; 95% CI = 1.74–7.71). In summary, several clinical factors are linked with the duration of SARS-CoV-2 RNA shedding. Disease severity is positively associated with the duration of viral shedding, while bilateral lung infiltrates, diabetes mellitus, and antibiotic treatment are negatively linked with the duration of viral shedding. Overall, our findings suggest the need to consider different isolation period estimations for specific clinical characteristics of patients with COVID-19 that affect the duration of SARS-CoV-2 RNA shedding.

Abstract Background Angiotensin receptor blocker and a neprilysin inhibitor (ARNI) has emerged as an innovative therapy for patients of heart failure with reduced ejection fraction (HFrEF). The purpose of this study was to assess the safety and tolerability of Sacubitril/Valsartan in patient with HFrEF in Pakistani population. Methods This proof-of-concept, open label non-randomized clinical trial was conducted at a tertiary care cardiac center of Karachi, Pakistan. Patients with HFrEF were prescribed with Sacubitril/Valsartan and followed for 12 weeks for the assessment of safety and tolerability. Safety measures included incidence of hypotension, renal dysfunction, hyperkalemia, and angioedema. Results Among the 120 HFrEF patients, majority were male (79.2%) with means age of 52.73 ± 12.23 years. At the end of 12 weeks, four (3.3%) patients died and eight (6.7%) dropped out of the study. In the remaining 108 patients, 80.6% (87) of the patients were tolerant to the prescribed dose. Functional class improved gradually with 75.0% (81) in class I and 24.1% (26) in class II, and only one (0.9%) patient in class III at the end of 12 weeks. Hyperkalemia remains the main safety concern with incidence rate of 21.3% (23) followed by hypotension in 19.4% (21), and renal dysfunction in 3.7% (4) of the patients. Conclusions Sacubitril/Valsartan therapy in HFrEF patients is safe and moderately tolerated among the Pakistani population. It can be used as first line of treatment for these patients. Trial registration NCT05387967. Registered 24 May 2022—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05387967

Background: Congenital insensitivity to pain (CIP) is a rare genetic disorder characterized by the inability to experience pain. Unrecognized, repeated injuries may result in poorly healed fractures with hyperplastic callus formation, auto-amputation of digits, and osteomyelitis. In addition, the loss of joint proprioception leads to neuropathic osteoarthropathy (Charcot joints). Case report: A child with a progressively increasing swelling of the left proximal tibia and an aggressive bone lesion on imaging was suspected to have osteosarcoma. The diagnosis of hyperplastic callus formation was established through a multidisciplinary approach with imaging and repeat tissue biopsy. Conclusion: In the context of CIP, malignant bone tumors, including osteosarcoma are a differential diagnosis and require a review of history, examination, radiology and histology.

Purpose: The purpose of our study is to correlate grade of Muscle invasive urothelial carcinoma with prognosis of patients in terms of disease recurrence, metastasis and death. Materals and methods: We retrieved 48 cases of invasive urothelial carcinomas which on initial presentation had invaded muscularis propria (pT2) or beyond muscularis propria (pT3 or pT4), diagnosed and treated in Shaukat Khanum Memorial hospital Lahore and whose 8–20 years follow up data was available in hospital archives received either as Transurethral resection or cystectomy specimens from 2002 to 2015. Cases diagnosed as primary adenocarcinomas, Neuroendocrine carcinomas or other bladder malignancy other than urothelial carcinoma were excluded. Results: All 48 pT2 and higher stage patients were high grade. 34/48(70.8%) patients had disease recurrence, 11/48(22.9%) had no recurrence of disease and 3 patients lost to follow up. 43/48(89.5%) patients developed disease metastasis while 5/48(10.4%) did not develop metastatic disease. 39/48(81.2%) died of disease, 3 patients lost to follow up while 6/48(12.5%) patients survived. 5 out of 6 patients who survived had underwent cystectomy while 6 more underwent cystectomy but still died of disease. Conclusion: Muscle invasion is itself an independent prognostic factor in predicting prognosis of patients and grade of such tumors is not much helpful as either majority of tumors are high grade or even if they are low grade, the prognosis is not good.

Objective: To differentiate malignant mesothelioma from benign mesothelial proliferations and other histological mimickers such as adenocarcinoma and squamous cell carcinoma, utilizing BRCA Associated protein1 (BAP1) immune-histochemical stain. Study Design: Retrospective longitudinal study. Place and Duration of Study: Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore Pakistan, from 2015 to 2020. Methodology: We examined BAP1 IHC expression in 82 cases, including 56 malignant mesotheliomas, 12 Adenocarcinomas, and 14 Squamous cell carcinomas. Fifty-six malignant mesotheliomas included 49 epithelioid, 6 Biphasic and one sarcomatoid subtype. Loss of expression was established for cases showing complete loss of nuclear staining. Results: Of 56 malignant mesotheliomas, 38(67.85%) showed loss of BAP1 expression, whereas 18(32.14%) showed retained expression. Of 12 adenocarcinoma cases, 10(83.33%) showed retained expression. Similarly, out of 14 squamous cell carcinomas, 12(85.71%) showed retained expression. Conclusion: Loss of nuclear expression of BAP1 IHC serves as a valuable diagnostic ancillary tool in distinguishing malignant mesothelioma from its histological mimickers. Keywords: BAP1, Immunohistochemistry, Malignant mesothelioma.

Tuberculosis (TB) is generally known as an infectious disease caused by Mycobacterium tuberculosis. Not only the lungs, TB can also infect various other organs. Pancreatic TB is a rare manifestation of extrapulmonary TB infection accounting for only 0-4.7% of the total TB cases worldwide. It’s still intricating for clinicians to diagnose pancreatic TB due to the extremely rare prevalence and non-specific clinical signs and symptoms. Herein we report a 71-year-old male patient complaining of jaundice and weight loss. Clinical condition, laboratory and tumor markers, also MRI imaging showed no abnormality. We made the diagnosis through histopathological examination of tissues extracted from bypass biliodigestive procedure, showing granulomas, along with confirmed bacteriological analysis with Ziehl Nelsen staining. This patient received Fixed Drug Combination (FDC) of anti-tuberculosis therapy for 6 months. The patient gained weight, had an improvement of serum bilirubin level and had no remaining lesion in abdominal CT scan.

Objective: To analyse the clinicopathological characteristics of sinonasal malignancies in the light of the updates regarding head and neck tumours. Method: The retrospective study was conducted at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised data of patients diagnosed with primary malignant tumours of the sinonasal tract between 2015 and 2020. Slides related to biopsies and resection specimens were retrieved from the institutional database and reviewed by two pathologists. Follow-up data was also obtained. Data was analysed using SPSS 20. Results: Of the 245 samples, 144(58.7%) were epithelial tumours, 46(18.7%) neuroectodermal tumours, 41(16.7%) hematolymphoid tumours and 14(5.7%) were malignant soft tissue tumours. A heavy reliance was placed on immunohistochemical stains to diagnose poorly-differentiated tumuors. Survival was dismal, especially with early and frequent spread to the brain (33.3% in cases of Sinonasal Undifferentiated Carcinoma). Conclusion: A wide array of sinonasal malignancies was seen. Updated knowledge of the malignancies prevalent in the region is imperative for timely diagnosis and treatment. Key Words: Sinonasal tract, Squamous cell carcinoma, Sinonasal undifferentiated carcinoma, NUT c, Survival, Pakistani.

Syphilis, an infectious disease caused by the spirochete Treponema pallidum, represents a pervasive global epidemic. Secondary syphilis is typically marked by the emergence of highly contagious mucocutaneous manifestations, including non-pruritic rashes on the palms and soles of the feet, alopecia, mucous patches, and condyloma lata. Here, we report a rare case of a 30-year-old male with newly discovered type 2 diabetes mellitus who presented with severe odynophagia due to secondary syphilis, confirmed by both nontreponemal VDRL/RPR and treponemal TPHA tests. Following the administration of a single-dose intramuscular injection of benzathine penicillin G 2.4 million units, the symptoms gradually decreased, allowing the patient to regain his health.

Ancient manuscripts are a rich source of history and civilization. Unfortunately, these documents are often affected by different age and storage related degradation which impinge on their readability and information contents. In this paper, we propose a document restoration method that removes the unwanted interfering degradation patterns from color ancient manuscripts. We exploit different color spaces to highlight the spectral differences in various layers of information usually present in these documents. At each image pixel, the spectral representations of all color spaces are stacked to form a feature vector. PCA is applied to the whole data cube to eliminate correlation of the color planes and enhance separation among the patterns. The reduced data cube, along with the pixel spatial information, is used to perform a pixel based segmentation, where each cluster represents a class of pixels that share similar color properties in the decorrelated color spaces. The interfering, unwanted classes can thus be removed by inpainting their pixels with the background texture. Assuming Gaussian distributions for the various classes, a Gaussian Mixture Model (GMM) is estimated through the Expectation Maximization (EM) algorithm from the data, and then used to find appropriate labels for each pixel. In order to preserve the original appearance of the document and reproduce the background texture, the detected degraded pixels are replaced based on Gaussian conditional simulation, according to the surrounding context. Experiments are shown on manuscripts affected by different kinds of degradations, including manuscripts from the DIBCO 2018 and 2019 publicaly available dataset. We observe that the use of a few PCA dominant components accelerates the clustering process and provides a more accurate segmentation.

Background. The updated version of predictive classification for immunoglobulin A nephropathy (IgAN) prognosis “The Oxford Classification” identifies five histopathological features including mesangial hypercellularity (M), endocapillary proliferation (E), segmental glomerulosclerosis (S), tubular atrophy/interstitial fibrosis (T) and crescents (C), the MEST-C. However, few studies suggest that tubulointerstitial inflammation, which is not included in the MEST-C, is also linked to disease progression and is, consequently, a neglected determinant of prognosis among others. Therefore, there is a need to evaluate this histopathological parameter in patients with IgA nephropathy. Materials and Methods. This cross-sectional descriptive study was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan. Data of histopathological and immunofluorescence proven renal biopsies (300) of IgA nephropathy patients from January 2016 through May 2022 were extracted using a convenient sampling technique. Biopsies were histologically reviewed for type and severity of tubulointerstitial inflammation, in addition to the MEST-C score. Renal biopsies of patients who had a history of transplant, autolyzed tissue, no glomeruli on histological examination, and/or a tubular atrophy/interstitial fibrosis score of 2 (T2) in MEST-C scoring were excluded. Data were analyzed using SPSS 20. An association between the variables was analyzed using the chi-square and Fischer exact tests. A p value less than 0.05 was considered statistically significant. Results. A total of 247/300 biopsies were eligible for inclusion. The mean age at the time of biopsy was 31.90 ± 12.48 with 63.6% in the age group between 21 and 40 years, and 69.6% were male. Tubulointerstitial inflammation was observed in 90.2% cases with 49.4% showing moderate while 4.5% showing severe degree of inflammation. A strong association of both the type and severity of tubulointerstitial inflammation was found with M, E, T, and C scores (p value < 0.05). Conclusion. The high-frequency and strong statistical association of tubulointerstitial inflammation with the M, E, T, and C scores in our study elucidate its prognostic role in the progression and management of IgA nephropathy.

Tillage is an important factor affecting different soil properties and crop yields. Tillage relates to applying forces to soil using different implements for preparation of a proper seed bed. For rice crop, land preparation is a rigorous and time consuming operation that needs special attention for preparing a puddled soil condition to transplant the weak and tender rice seedlings. A field experiment was established under agro-ecological conditions of Sheikhupura to evaluate different land preparation techniques during fall in 2017 and 2018 years. The experiment was performed at Adaptive Research Farm Sheikhupura. It was laid out in randomized complete block design (RCBD) with four different land preparation techniques including T1= Cultivator (4 times) + Planking (2 times) (Farmer’s Practice), T2=MB plough (1 time) + Disc Harrow (1 time) + Planking (2 Times), T3=MB plough (1 time) + Cultivator (2 times) + Planking (2 Times) and T4= Rotavator (1 time) + Disc Harrow (1 time) + Planking (2 Times), each treatment replicated thrice during both the years. All the other agronomic and crop husbandry operations were kept uniform throughout the growing season every year. The results revealed that preparing land with MB plough (1 time), Disc Harrow (1 time) and Planking (2 times) is the best land preparation method can increase the paddy yield 13.5-17.5% as compared to the traditional method practised by the farmers. Moreover, highest plant height (134.00 cm and 132.00 cm), number of tillers (224 and 220 m-2), number of grains per spike (130 and 116) and 1000-grain weight (23.0 and 22.0 g) respectively during Kharif-18 and Kharif-19 was also recorded in the same treatment. So, preparation of land for paddy in agro-ecological conditions of Sheikhupura using MB plough (1 time), Disc Harrow (1 time) and Planking (2 times) can significantly enhance the paddy yield.

Objective: to determine unusual morphological features and a panel of immunohistochemical markers to diagnose Xp11 translocation carcinoma. Study Design: Retrospective longitudinal study. Place and Duration of Study: Shaukat Khanum Memorial Cancer Hospital, Lahore Pakistan, from Jun 2015 to Feb 2020. Methodoldogy: We analyzed clinicopathological features, and evaulated intensity and extent of TFE 3 immunoreactivity of 18 cases with suggested diagnosis of xp11 translocation associated renal cell carcinoma from 2015-2020. Results: Different morphological pattern includes papillary (8/18, 44%), nested (2/18, 11.1%), alveolar (3/18, 16.7%), nested and papillary (3/18, 16.7%), solid and nested (1/18, 5.6%), cystic and nested (1/18, 5.6%). Four cases show papillary architecture with a linear array of nuclei away from the basement membrane, a pattern seen in SFPQ-TFE3 renal cell carcinoma and NONO-TFE3 renal cell carcinoma. Strong nuclear TFE3 expression was seen in 9/18 (50%) cases. Cathepsin k expression was seen in 6/11 (54%) cases, Ck7 was focal weak positive in 4/12 (25%) cases, PAX8 was positive in 8/8 (100%) cases, and CA IX was focal weak positive in 1/5 (20%) case. According to follow-up data, disease progression was seen in only one case with the low-stage disease. No death was reported due to renal cell carcinoma to date of follow-up. Conclusion: We have suggested that young patient age, unusual morphological features and an immunohistochemical panel may help reach the diagnosis in countries with limited resources.

Introduction: Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections in the intensive care unit (ICU). Mechanically, ventilated patients have a higher risk of VAP. VAP can increase morbidity, mortality, and treatment costs. However, Indonesia lacks data about VAP. The objective of this study was to find out the characteristics of VAP in Dr. Soetomo General Hospital, Surabaya, in the period of August 2017 until August 2018. Methods: This was a cross-sectional study by assessing medical records of the patients in ICU. The variables observed in this study were age, gender, outcome, length of stay in the ICU (LOSICU), and primary diagnosis. The inclusion criteria were the patients who have been using mechanical ventilation at least 2 x 24 hours in the ICU and confirmed VAP. The data were analyzed descriptively by using Microsoft Excel 2016. Results: A total of 18 VAP patients were diagnosed. VAP patients were dominated male (55.6%). The mean of LOSICU was 22.83 ± 11.24 days, and the mortality rate of VAP patients was high (55.6%). 30% of VAP patients had Guillain-Barre Syndrome (GBS) as the primary diagnosis, and 16.65% had Congenital Heart Disease (CHD). Conclusion: Most VAP patients were male and had prolonged stays. The mortality rate of VAP patients was still high. GBS was the most frequent of primary diagnoses in patients with VAP and also CHD.

Purple urine bag syndrome (PUBS) is an unusual manifestation of urinary tract infection, characterized by purple discoloration of urine. Due to its rarity, it can be challenging for some physicians to manage it properly. In addition, its striking appearance can cause concern to some patients. This condition usually occurs in the debilitated geriatric population with prolonged use of an indwelling urinary catheter. However, our case highlights the development of PUBS in a young adult with a relatively short period of urinary catheterization.

Epstein-Barr Virus can cause various diseases, from acute inflammatory diseases such as fatal or chronic EBV infection, infectious mononucleosis as well as lymphoid and epithelial cancer, various autoimmune diseases, and also could interact with malaria. As EBV infects 95% of the world population, and more than 30% are infected with the protozoan parasite, with more than 500,000 deaths due to malaria cases. It is important to understand how EBV dysregulates the immune system, especially when the virus is interacting with other pathogens such as malaria parasites, causing more severe conditions in certain people like Burkitt Lymphoma. This review will be informative about the mechanism of how EBV interacts with malaria parasites and how it affects the immune system. Knowledge of various cytokines triggering the immune system which may provide links to control/minimize malaria disease severity.