opposite to the editorial
Circulating tumor cells (CTCs) are the precursors to metastases and increased numbers of CTCs in the peripheral circulation have been shown to correlate with decreased progression-free and overall survival. Although the current clinical utility has been focused on the prognostic significance, other clinical applications are being explored, such as determining if a patient is a candidate for treatment, determining the efficacy of treatment, evaluation for resistance to therapy, prediction of metastatic site, or as an early predictor of metastases. Current methodologies are based on quantifying CTCs and include technologies based on physical, immunological, and molecular techniques. However, these have limitations, of which most of them do not have the ability to perform morphological evaluation. Using morphological evaluation, CTCs in body fluids could be used for primary diagnosis in the setting of cancer of unknown primary (CUP) or in initial or early diagnostic scenarios. Additionally, cytological specimens have been shown to be useful for ancillary testing in patients when surgical resection specimens or biopsies are not available. Evaluation of CTCs should incorporate histological, immunehistochemical, and molecular characterization to enable clinicians to obtain the comprehensive diagnostic, prognostic and therapeutic information necessary to provide appropriate personalized care to cancer patients.
Circulating tumor cell (CTC); Circulating; Tumor cell; Cancer; Isolation; Detection; Metastasis; Prognosis.
CTC: Circulating tumor cell; RT-PCR: Reverse transcriptase-polymerase chain reaction; EMT: Epithelial-mesenchymal transition; MET: Mesenchymal-epithelial transition; TRAIL: Tumor necrosis factor-related apoptosis-inducing ligand; CEA: Carcinoembryonic antigen; CUP: Cancer of unknown primary; CAP: College of American Pathologists; AMP: Association for Molecular Pathology; ASCO: American Society of Clinical Oncology.
Deoxyribonucleic acid (DNA) microarrays are collections of DNA probes arranged on a base pair and the latest commercialized molecular diagnostic technologies that offer high throughput results, more sensitive and require less time. It is the most reliable and widely accepted tool facilitating the simultaneous identification of thousands of genetic elements even a single gene. Microarrays are powerful new tools for the investigation of global changes in gene expression profiles in cells and tissues. The different types of DNA microarray or DNA chip devices and systems are described along with their methods of fabrication and their use. The DNA microarrays assembly process is automatized and further miniaturized. DNA microarrays are used in the search of various specific genes or in gene polymorphism and expression analysis. They will be widely used to investigate the expression of various genes connected with various diseases in order to find the causes of these diseases and to enable their accurate treatment. Generally, microarray analysis is not only applied for gene expression studies, but also used in immunology, genotyping, diagnostics and sequence analysis. Additionally, microarray technology being developed and applied to new areas of proteomics, cancer research, and cellular analysis.
Application, DNA, Microarray, Principle.
This case documents the treatment of a middle-aged woman with chronic, unresponsive adhesive capsulitis (frozen shoulder) using manipulation, active release therapy, and electronic acupuncture. She had not responded to typical physical therapy but did respond to active release therapy along with adjunctive manipulation and acupuncture. In our course of treatment we wanted to see if we could significantly improve pain-free range of motion and normal; function without using invasive treatments like surgery and manipulation under anesthesia. Over a course of five weeks, using a soft tissue manipulation technique known as active release technique along with electrified acupuncture and home exercises, we were able to increase her range of motion to near normal and her function to normal. She was not forced to miss any work because of the treatment and can now do all the things she needs to do for work.
Frozen shoulder; Adhesive capsulitis; Manipulation; Active release therapy; Non-invasive treatment.
Perniosis or chilblain pernio is an inflammatory skin disease, typically located on acral skin surfaces secondary to prolonged exposure to cold temperatures and damp conditions. This disorder can appear as an idiopathic dermatosis, usually in young women, but occasionally it is associated with diseases such as anorexia, intestinal lymphoma, chronic myelomonocytic leukemia, monoclonal gammopathies, cryoproteinaemia, viral infections, as well as connective tissue diseases, especially lupus, picture that is known as chilblain lupus. We present a case of perniosis associated with Systemic Lupus Erythematosus and review the literature.
Chilblain lupus; Perniosis; Chilblain pernio; Rare cutaneous; Myelomonocytic leukemia; Systemic Lupus Erythematosus.
Everyday all of us use rechargeable solutions either its smartphones, televisions, or any other electronic devices. Faster streaming of these electronic devices to other external devices may be facilitated through wireless connectivity. Wireless streaming demands much more battery backup. With advancement of hearing aid technology many features exists in hearing aids which may facilitate better spectral information, improved speech understanding in presence of background noise and thus improving communication and quality of life of the users. The use of these advanced features often requires continuous uninterrupted power supply. Traditional disposable hearing aid batteries cannot be assured of their performance due to their inopportune time discharge. Recently rechargeable solutions in hearing aids have been discovered that can support long-lasting wireless streaming. Modern day rechargeable batteries are expected to be easy to charge which can last for longer duration with more reliability and durability. Rechargeable as a feature is added on over and boon. Rechargeable battery solutions based on its various benefits may support as boon for environment, hearing aid users and professionals (better counseling and more satisfied users). The aim of this article is to highlight the awareness of these different rechargeable solutions for the users and professionals. In addition mentioning in brief the superiority of Lithium ion battery which is widely accepted in rechargeable hearing aids.
Rechargeable hearing aids; Wireless streaming; Batteries for hearing aids; Li-ion batteries.
Bone grafting is a surgical procedure that replaces missing bone through transferring bone cells from a donor to the recipient site and the graft could be from a patient’s own body, an artificial, synthetic, or natural substitute. Bone grafts and bone graft substitutes are indicated for a variety of orthopedic abnormalities such as comminuted fractures (due to car accidents, falling from a height or gunshot injury), delayed unions, non-unions, arthrodesis, osteomyelitis and congenital diseases (rickets, abnormal bone development) and are used to provide structural support and enhance bone healing. Autogenous, allogeneic, and artificial bone grafts are common types and sources of grafts and the advancement of allografts, synthetic bone grafts, and new operative techniques may have influenced the use of bone grafts in recent years. Osteogenesis, osteoinduction, osteoconduction, mechanical supports are the four basic mechanisms of bone grafting and help bone tissue to regenerate completely. A bone graft can be harvested from the iliac crest, proximal tibia, proximal humerus, proximal femur, ribs, and sternum. An ideal bone graft substitutes should be biologically inert, readily available, must possess osteogenic, osteoinductive and osteoconductive properties, provide mechanical support, easily adaptable in terms of size, shape, length and substituted by the host bone. Bone banks are the source of bone grafts and implants and necessary for providing biological material for a series of orthopedic procedures. Bone grafts and implants can be selected as per clinical problems, the equipment available and the preference of the surgeon. A search for an ideal bone graft is on and may continue time to time.
Application; Bone; Bone graft; Bone replacement; Bone bank; Principle.
To describe our myositis cohort in-depth.
From January 2006 to December 2018, all newly diagnosed myositis patients were retrospectively enrolled in the study. We performed a subtype reclassification using the 2017 EULAR/ACR criteria, following the example of the EuroMyositis registry. Disease activity and damage were measured by the newest standardized assessment-tools for clinical studies. Comparisons between myositis subgroups were conducted using Fisher’s exact test.
We enrolled 32 patients (25 were female): six patients with dermatomyositis, six with polymyositis, eleven with overlap myositis, six with antisynthetase syndrome, one with autoimmune necrotizing myopathy, one with juvenile antisynthetase syndrome and one with juvenile dermatomyositis. The overall median follow-up period was 23-months (9-44.75). Interstitial lung disease (ILD) was most frequently seen in patients with antisynthetase syndrome. Patients with overlap myositis were more likely to have polyarthritis mimicking rheumatoid arthritis, reduced capillary density in the nail fold capillaroscopy and Raynaud syndrome. Ovarian cancer during the follow-up period occurred in two patients (one with polymyositis and one with dermatomyositis). Myositis-related death was reported in two patients: acute respiratory failure in autoimmune necrotizing myopathy and dysphagia-related complications in polymyositis. Cyclophosphamide, methotrexate and rituximab demonstrated a significant steroid-sparing effect. In 22 of 32 patients, the myositis subgroup classifications made on the basis of our opinion and the new EULAR/ACR classification criteria were different, showing strong disagreement, especially in the subtype polymyositis.
Our analysis highlights the heterogeneity in myositis subgroups and shows the steroid-sparing effect of cyclophosphamide, methotrexate and rituximab.
Myositis; Idiopathic inflammatory myopathy; Dermatomyositis; Antisynthetase syndrome; Overlap myositis; Rituximab.
CCP: Cyclic Citrullinated Peptide; CK: Creatine kinase; CYC: Cyclophosphamide; IIM: Idiopathic Inflammatory Myopathy; ILD: Interstitial lung disease; IMACS: International Myositis Assessment and Clinical Studies Group; MDI: Myositis Damage Index; MMT8: Manual muscle test 8; MTX: Methotrexate; MYOACT: MYOsitis disease ACTivity; RTX: Rituximab; TIF-1γ: Transcriptional factor-1γ.
Cutaneous polyarteritis nodosa is a rarer variant of classic polyarteritis nodosa with unknown etiopathogenesis. It presents with skin, articular and nervous involvement, after systemic involvement is ruled out. This work reports the case of a 41-year-old male patient diagnosed with cutaneous polyarteritis nodosa with skin lesions, polyarthralgia and sensory axonal polyneuropathy.
Skin; Polyarteritis; Vasculitis; Biopsy; Immunofluorescence; Histology.
Esophageal replacement (ER) is indicated in patients with long gap esophageal atresia (LGEA) or failure of the primary anastomosis. Also, severe caustic or peptic strictures, resistant to conservative treatment with medication and dilations, may require an ER. Numerous techniques with different organs and routes have been described, all with satisfactory results.
Our objective is to describe the experience obtained with partial gastric pull-up according to the Schärli principles (SGPA).
Materials and Methods
Medical records of patients who required a SGPA between October 1995 to June 2018 were reviewed. The analysis was observational, longitudinal, retro-prospective and descriptive. Epidemiological data, surgical aspects and postoperative complications of the patients were considered.
Seventy ER were performed with SGPA. The indication was esophageal atresia (EA) in 58 cases (44 long gap and 14 failure of the anastomosis), 10 caustic strictures, one peptic stricture resistant to conservative treatment and the other due to a retained foreign body. The age of the ER was on average 2-years and 9-months. The route was: posterior mediastinal (35), retrosternal (29) and transpleural (6); without a thoracic approach in 59 patients. The duration of the procedure was 4.7-hours on average. There were 13 cases of intraoperative complications, 8 cases of pneumothorax, 5 bleeding injuries (3 in the spleen, 1 liver and 1 cervical), and one injury to the cervical trachea. Anastomotic dehiscence was observed in 37 patients (52%), which closed spontaneously after an average of 17.8-days in all except one patient. Thirty-one patients (44%) developed anastomotic stenosis, requiring redo anastomosis in 6 cases; 37% developed dumping and 23% gastroesophageal reflux disease. There were 3 deaths (4.2%): all in EA patients with associated malformations, following a morbid postoperative period with infectious complications in intensive care at 10-days, 7 and 8-months after ER. Follow-up was an average of 8-years. All 67 living patients are currently tolerating oral feeding.
In our experience with ER using SGPA, we observed a high incidence of complications, generating a longer post-operative evolution and with greater morbidity than that described in other techniques. Given these results, we changed our strategy to complete gastric transposition, in order to reduce morbidity and improve the evolution of this complex group of patients.
Esophageal replacement; Partial gastric pull-up; Esophageal atresia; Caustic stricture.
Connected care is defined as the “real-time, electronic communication between a patient and a provider, including telehealth, remote patient monitoring, and secure email communication between clinicians and their patients” (Alliance of Connected Care). Connected care can create a high-value interaction strategy with patients when it makes thoughtful use of commercially available digital health technologies with demonstrated both clinical and economic effectiveness. Karantis360™, is a home sensor technology that enables real-time tracking, data analytics and predictive care for personal (at home) care powered by IBM Watson Health. IndividuALLyticsTM is a telemedicine platform driven by a patent-pending an N-of-1 analytical engine and related digital dashboards that provides individual, patient level evaluation of treatment response. The underlying technology combines disparate digital health technology data with the best evidence-base guidelines with N-of-1 methodology. The output allows for creation of personalized treatments empirically tested at the patient level over time (aka over the course of care). When aggregated both within and across persons,
the time-ordered data can build predictive pathways of behavior and ensure the relevant care and medical treatments are in place to support effective medical and self-management of chronic illness. This case-series report describes the implementation of a joint home sensor technology (big data) and an N-of-1 analytic engine (small data) with three elderly consented volunteer customers-patients of Karantis360™. Each person underwent successive, 2-week behavioral change treatment phases to determine usability, utility regarding medical and self-management and any proximal effects on health risks.
Telemedicine; Small data; n-of-1; Internet of things; Chronic conditions; Self-management; Predictive analytics.
Paediatric urolithiasis is an emerging disease in developing nations especially in India, but a rarer entity compared to its adult counterpart. There is significant geographic variation in the incidence of urolithiasis within India itself. Given the changing dynamics of the disease, this study evaluated paediatric urolithiasis patients in a non-endemic region in South India.
This is a retrospective study of children and adolescents diagnosed with urolithiasis from January 2009 to December 2019 in a single tertiary care centre in South India. The purpose of this study was to investigate and identify the demographic and clinical characteristics, aetiology, management, clearance rates after surgical intervention and disease recurrence of paediatric stone disease
in a non-endemic region in South India.
We evaluated 29 patients which included a total of 97 hospital admissions. Predominantly the study population consisted of males (80.0%), with a mean age of symptom onset of 9.44±5.53-years. All patients were metabolically evaluated, 16 patients (55.2%) had metabolic abnormalities and the most common abnormality was hypocitraturia (37.5%). Spontaneous elimination rate was 6.9% and clearance rates for surgical procedures ranged from 72% to 100%. Recurrent stones were seen in 37.9%. No patient developed chronic kidney disease or mortality due to stone disease within the evaluation period of this study.
Paediatric urolithiasis is an emerging disease in India. There is a high prevalence of metabolic abnormalities in paediatric stone disease which supports the need for metabolic evaluation in all cases. There is more similarity of our study with western literature than the available Indian data which may be due to the lifestyle changes, significant geographic variation within India itself between
endemic and non-endemic regions or changing epidemiology of paediatric stone disease per se.
Paediatrics; Urolithiasis; Urinary tract infection (UTI).
Glomus tympanicum is a tumor classified as a paraganglioma. We report a case of a 66-year-old female with two middle ear pathologies: an incidental finding of a glomus tympanicum during stapedotomy surgery for otosclerosis.
Glomus tympanicum; Otosclerosis; Paraganglioma; Stapedotomy.
The present study investigated the effects of cypermethrin exposure on humoral and cellular immune response in rat and its attenuation by zinc and alpha-lipoic acid.
Cypermethrin at the dose levels of 40 mg and 80 mg/kg body weight were orally administered and pre-treatment of zinc (227 mg/L in drinking water) and alpha-lipoic acid (35 mg/kg body wt.) were done. Total leukocyte and differential leukocyte counts (DLC), phagocytic index, serum nitric oxide (NO) activity, total immunoglobulin concentration, quantitative hemolysis, proliferation assay of blood mononuclear cells were estimated and histological examination of spleen was accomplished.
Total white blood cell (WBC) count and percentage of lymphocyte, serum nitric oxide activity (p<0.001) and quantitative hemolysis were increased significantly increased whereas neutrophil %, total serum immunoglobulin, and blood mononuclear cell proliferation (p<0.001) and the phagocytic function of peritoneal macrophages were significantly reduced in cypermethrin treated rats compared to control group rats at a dose-dependent manner. Zinc and alpha-lipoic acid pre-treatment reversed the results.
From the findings it can be concluded that the co-administration of zinc and alpha-lipoic acid significantly attenuated the immunotoxic effects in cypermethrin exposed rat.
Cypermethrin; Zinc and alpha-lipoic acid; Total serum immunoglobulin; Blood mononuclear cell proliferation; Phagocytic index.
The thyroid cancer in Pakistan is accountable for 1.2% cases of all cancers. Earlier information from Pakistan showed papillary thyroid carcinoma (PTC) to comprise 57-89% of all thyroid malignancies As per World Health Organization (WHO), papillary microcarcinoma of thyroid (PMCT) is a small area of malignant transformation measuring up to 1 cm or less being defined by WHO, that is currently being diagnosed more often than the past. Albeit small, they have the capability of metastasizing to regional lymph node and may disappear after metastasis.
To evaluate the prevalence of PMCT in benign multinodular goiter in thyroidectomy specimens.
The study was performed in Histopathology Laboratory of Peshawar Medical College, where 32 specimens of multinodular goitre (MNG) patients were received from its affiliated hospitals. The patients’ details were obtained from the hospital records. The specimens were closely examined for the presence of suspicious foci both grossly and microscopically. Results obtained were
recorded and data was analyzed statistically.
All the 32 specimens of the patients were thyroids. The results show a predominance of female patients in surgically resected MNGs with a relatively low incidence of neoplastic transformation. Our study reported two cases of PMCT and both were from different age groups, one was below 25-years and the other was 48-years. Patients mean age was 38.63-years with a SD±12.95-years. The size and weight of the samples varied. The mean of weight was 206.31±304.50 grams, which is due to the reason that many outliers were noted in weight category.
In thyroid excisions the weight of the excised specimen holds much great importance in determination/diagnosis of the disease. The risk of malignancy is higher in MNG compare to solitary nodules. The prevalence of PMCT (6.25%) are higher in smaller nodules is compare to PTC (3.12%). Furthermore, the fact that our both PMCTs occurred in total thyroidectomy specimens cautions us for their prudent assessment both in gross and histopathological levels.
Papillary microcarcinoma thyroid; Multinodular goiter; Thyroidectomy.
Background and Goal of Study
Chronic post-operative pain (CPOP) is an increasing public health issue considering its impact on the patients quality of life and and the associated costs for the healthcare system. The incidence of CPOP can be as high as 75%, depending on the surgical procedure and other factors. Lidocaine is a local anesthetic with anti-inflammatory, analgesic and antihyperalgesic properties. Several studies have shown its use in controlling acute post-operative pain when used intravenously. The goal of this study was to define the role of intravenous lidocaine in preventing CPOP.
Materials and Methods
The PubMed database was searched from 2006 and 2019 with the keywords: “Chronic post-operative pain” or “Chronic post-surgical pain” or “Chronic pain” and “Intravenous lidocaine”. Adequate papers for the purpose of this study were selected.
Results and Discussion
Three randomized controlled trials that met criteria were obtained: two on breast surgery and the other on open nephrectomy. All trials used intravenous lidocaine during surgery, suspending the infusion up to the first 24-hours of the post-operative period. All three of them showed a significant decrease on the incidence of CPOP. There was a 20-fold decrease six months after breast
Intravenous lidocaine seems to decrease the incidence of CPOP however, there is limited evidence. More trials are necessary to define the efficacy and safety of intravenous lidocaine. A generally accepted definition of CPOP is needed.
Chronic pain; Chronic post-operative pain; Chronic post-surgical pain; Intravenous lidocaine.
The purpose of this study was to 1) compare the body composition values of an active group of breast cancer survivors (BCS) determined by dual X-ray absorptiometry (DXA) and anthropometry, and 2) compare the bone mineral density of the upper thoracic region to assess the effect of tumor burden on bone health.
Design and Methods
Forty (n=40) breast cancer survivors from a local competitive Dragon Boat Team were measured as part of team assessments. ANOVA with Dunn’s post-hoc testing was used to compare results of DXA, body density, and body composition estimated from anthropometry. Bland-Altman testing and correlational analysis were calculated.
Percentage of fat measure by DXA was significantly higher than values used to estimate body fat from skinfold measures or from body density equations (DXA 41.1±6.0% vs. 3-site skinfolds 28.8±4.9%, 4-site skinfolds, 22.1±4.1%, skinfold and body density, 31.8±9.4%, respectively, p<0.05). Post-hoc testing revealed that all values were significantly different and the strongest correlation
with DXA was skinfolds at three sites was r=0.81. Regional (upper thoracic) bone mineral density was not significantly different based on tumor side diagnosis (breast cancer diagnosis side versus healthy, 0.971±0.198 vs. 0.988±0.190 gm*cc-1). Anthropometry and bilateral bone mineral density characteristics are presented to serve as a comparative sample of BCS for future studies.
As body composition is an important factor in long-term cancer survivorship, we found the use of skinfold measures inadequate to accurately determine percentage of fat in this group of active female BCS. As a result, recommendations aimed at achieving an ideal body composition based solely on anthropometry would have grossly underestimated fat mass, which may lead to overall clinically poorer outcomes.
Breast cancer; Body composition; Percentage fat; Bone mineral density.
Neurological disorders are a ubiquitous part of our lives, and with innovative technological advancements there are increasing numbers of people being diagnosed with a variety of conditions. While these advances uncover the underlying pathological process, the requisite need to manage a patient’s condition necessitates renewed vigour in the realm of key therapeutics. This case study looks at a patient with a rare neurological condition, transverse myelitis (TM), and a complication that many spinal cord injury patients suffer, autonomic dysreflexia (AD). However, what makes this case unique is when the patient was administered with immediate-release Tapentadol, a synthetic opioid, the patient suffered more frequent and prolonged attacks of AD. The exploration
of the functional anatomy of TM as it applies to this case is highlighted, and how the role of Tapentadol was a causative agent in increasing the patient’s AD.
Spinal cord injury; Transverse myelitis; Pharmacokinetics; Opioids.
TM: Transverse myelitis; CNS: Central nervous system; AD: Autonomic dysreflexia; VAS: Visual analogue scale; MET: Medical emergency team.
Erectile dysfunction (ED) is a significant and common medical problem. Currently, there are several treatment available options for patients with ED, both non-invasive and invasive like phosphodiesterase 5 inhibitors, intra-cavernosal injections (BIMIX,TRIMIX), intraurethral prostaglandin E1 pellets, vacuum erection devices and insertion of a penile prosthesis. Most of these options are
invasive, which can be troublesome for patients, and also have side-effect profiles. Pulsed-electro magnetic stimulation therapy (PLMST) has gained interest in the field of sexual medicine. In the given case author presented a successful effect of in a case of erectile dysfunction.
Erectile dysfunction; Electromagnetic stimulation therapy; Latest treatment; Non-invasive treatment;
Erection hardness scale (EGS).
The substance abuse subtle screening inventory (SASSI) has been used successfully in correctional treatment settings and correctional screening since 1988. These screenings include outpatient evaluations of offenders within community settings, as well as assessments of incarcerated individuals within federal, state, city, and county correctional facilities. One key element towards reducing recidivism and reoffending, is that individuals receive treatment for substance use disorders (SUD’s) while in the correctional
system. While SUD is not the only contributing factor to criminality, it does significantly increase the likelihood of legal infraction and violations, placing these individuals at a higher risk of re-offending. Thus, identifying SUD as early as possible helps provide tailored treatment to those who need it, while simultaneously reducing the risk of future legal difficulties. Now in
its fourth iteration (SASSI-4), this article discusses the SASSI screening tools’ utility with criminal offenders and serving clinical needs, and reviews a case study of a young male’s clinical evaluation while incarcerated.
For this case study, we reviewed the SASSI-4 screening results of a 24-year-old male whom we will call “Bryon”. Bryon was in his 4th week of detention at a local mid-western jail in the United States. He was arrested after turning himself in for a prior domestic violence offense committed while under the influence of alcohol and for which he had fled the state. Bryon had one prior arrest (for receiving stolen property, which he subsequently traded for drugs). The intake counselor conducting Bryon’s assessment had been meeting with him at the jail for several weeks. The court was particularly interested in determining the level of risk that Bryon would again flee the area.
This case presents us with a good example of the value of early identification of substance use disorder, and potential problems in criminal justice settings. Bryon’s SASSI results clearly demonstrate a well-established pattern of substance misuse that will require relatively intensive intervention. Therefore, he may be a solid candidate for diversion into an alcohol and drug treatment program as a way of reducing the risk of future offenses.
Subtle SUD screening; The SASSI Institute; Criminal offenders; Corrections; Recidivism; Alcohol and drug screening.
Environmental toxicants have become a major source of health hazards to humans, thereby negatively impacting the health and overall well-being of exposed individuals. Among these environmental toxicants, heavy metals stand out as the major cause of tissue pathologies and threaten an individual’s health status. One such heavy metal is cadmium (CD) whose exposure has been linked to various tissue toxicities including nervous, respiratory, reproductive, cardiovascular, hepatic and renal tissues. Cadmium is a non-biodegradable heavy metallic which possesses a long half of lifestyles and comfortably accumulates inside the tissues in which it produces tissue toxicities main to tissue disorder. The present study was aimed to determine the amelioration capabilities of Vitamin C, E and Zinc from the harmful effects of CD in Wistar rats.
The Wistar strain male albino rats weighing 225±10 g were administered with CD along co-administered with Vitamin C, E and Zinc, individually and also in combinations. After the completion of 45-days of experimentation, certain specific enzymatic parameters were assayed in plasma serum to assess the impact of CD and protective effect of Vitamin C, E and Zinc.
Soon after the co-administration of CD along with Vitamin C, E and Zinc, either individually and in combinations, Body weights, liver weight and histo-somatic index (HSI) of liver and certain specific enzymes of plasma including aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), γ-glutamyl transferase (GGT), lactate dehydrogenase (LDH), creatinine, glucose and urea were monitored. All the parameters monitored showed a significant (p<0.05) increase during CD administration except ALP. All the parameters selected in the present study were shown to be significantly (p<0.05) reversed due to co-administration of Vitamin C, E and Zinc either individually or in combination, due to the protective effect from CD toxicity
in wistar rats.
Our results demonstrate that co-administration of Vitamin C, E and Zinc ably protects the toxicity of CD in Wistar rats significantly.
Cadmium; Wistar rats; Oxidative stress.
Cancer of the cervix is a common cause of malignancy. Its association with systemic lupus erythematosus (SLE) is debatable.
Early detection of cervical pre-neoplastic lesion in SLE patients.
A case control study was performed on 64 SLE group and 64 control group using a colposcopy, pap smear and histopathological examination.
This study revealed that preneoplastic and neoplastic lesions of the cervix were higher in the SLE group.
Systemic lupus erythematosus (SLE); Cancer; Cervix; Low grade squamous intra-epithelial lesions; High grade squamous-intraepithelial lesions; Cervical; Intraepithelial neoplasia; Squamous cell carcinoma.
ASCUS: Atypical squamous cells of undetermined significance; LGSIL: Low grade squamous intra-epithelial lesions; HGSIL: High grade squamous-intra-epithelial lesions; CIN: Cervical intraepithelial neoplasia; SQCC: Squamous cell carcinoma; SLE: Systemic lupus erythematosus.
Lower Urinary tract symptoms are common in patients with multiple sclerosis (MS) and have a negative influence on the quality of life (QoL). Detrusor overactivity is the most frequent symptom. Lifestyle modifications are the first therapeutic line followed by oral medication in patients with storage dysfunction. When these drugs are ineffective or intolerable, botulinum toxin bladder injection is an alternative treatment. The aim of this work is to evaluate the effectiveness and the impact on QoL of patients with MS and refractory or intolerant to oral therapy overactive bladder (OAB) after botulinum toxin type A bladder injection.
Materials and Methods
Retrospective study with six-months follow-up of patients with MS diagnosis and a refractory or intolerable to oral drugs OAB treated with botulinum toxin injections. All patients completed urological evaluation and a QoL questionnaire prior to the injection, 3 and 6-months after. Evaluation of the urodynamics tests prior and 3-months post injection was made.
Sixteen patients were treated. The QoL questionnaire showed progressive improvement 3 and 6-months after the injection. There was decrease in the number of daily voids urination and in the urinary incontinence episodes. There was an upgrade in the bladder capacity from 191 to 338 ml average (p 0.0004) and 75% evidenced disappearance of detrusor overactivity (p 0.0005). Thirteen (13) patients (81.25%) made spontaneous urination with post-voiding residue <100 ml after injection. Three (3) episodes of urinary tract infection were evidenced.
Botulinum toxin generates a positive impact on the QoL of patients with neurogenic OAB with MS.
Pinna swelling that is angiolymphoid hyperplasia is a benign lesion that needs to be discussed. Most of the time it affects the face in that preauricular area involved, where it appears as a tiny erythematous lesion. Here we reported a case of a 24-years female patient who presented to us at the hospital with left ear pinna swelling for 7-years.
Pinna; Swelling; Angiolymphoid; Hyperplasia; Eosinophilia.
The hindlimb suspended (HLS) rat model has been used in land-based research to evaluate effects of simulated microgravity. Previous research demonstrated that 2-4 weeks of HLS reduced vasoconstrictive responses of aortic, mesenteric, and femoral arterial rings to phenylephrine (PHE) while acute exposure to hyperoxia amplified constrictive responses to PHE. The purpose of this study was to determine if hyperbaric oxygen treatment (HBO) during HLS would reverse the attenuation of the vasoconstrictive response.
Five-month-old male Sprague Dawley rats were randomly divided into aging controls (AC), AC-HBO, HLS, and HLS-HBO. Groups receiving HBO (AC-HBO; HLS-HBO) were placed in a cage that was fitted for the animal hyperbaric chamber to maintain HLS. HBO groups received 24 treatments, once a day, 6 d/week using a wound care protocol. The chamber was flushed with 100% oxygen, compressed over 10 min to 2.5 atmospheres absolute (ATA) (22.5 psig), a 90-minute treatment, then a 10 min decompression. After 28 d of HLS, animals were sacrificed under isoflurane anesthesia and thoracic aorta segments isolated. Relaxation of aortic rings was measured in response to acetylcholine (ACh) and sodium nitroprusside (SNP) after pre-constriction with PHE (3×10-7). Constriction of aortic rings was also determined in response to increasing concentrations of PHE. All drugs were administered cumulatively in vessel baths at 10-10-10-4 M. Data were analyzed using four-parameter (i.e., minimum, maximum, EC50, slope) nonlinear regression, and groups compared using 2×2 ANOVA with HBO and HLS as main effects.
Responses to ACh and SNP were not affected by HLS or HBO. However, in response to PHE, there was a decrease in maximum vasoconstriction in HLS compared to controls (44.7±7.3% vs 82.4±6.0%, respectively, p≤0.05) and in HBO compared to controls (48.5±6.5% vs 78.6±6.8%, p≤0.05).
These results indicate that PHE-induced constriction of thoracic aorta is decreased after HLS. HBO did not reverse HLS-induced reductions in contractile responses; instead, HBO independently reduced PHE-stimulated constriction of aortic segments. This suggests that HBO may be useful in conditions where constriction is enhanced, such as diabetes.
Hyperbaric oxygen; Vascular reactivity; Hindlimb suspension.
This study was performed to investigate the effectiveness of two endoscopic techniques for transsexual females.
Web of Science, Google Scholar, and PubMed databases were searched for studies suitable for inclusion in this meta-analysis. Studies in which Wendler’s glottoplasty or laser-assisted voice adjustment were analysed for the data criteria. Studies which included
pre-operative and post-operative fundamentals frequency values were selected. Five articles were included in the present study (total of 94 cases). As dependent groups were used in these studies, standardized mean differences were obtained using a random effect model. Analyses were performed using the meta for package for the R-statistical program.
Standardized mean values before and after operations were very different and post-operative mean values were significantly higher than the pre-operative mean values.
Endolaryngeal surgical techniques are valuable for pitch elevation.
Transgender; Phonosurgery; Voice; Gender and the voice; Endoscopy US version.
The impact of human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) on individuals, communities and organisations is a major bone of resentment the world over. Human capital planning (HCP) focuses on helping managers set the direction for an organisation in regard to its future. Human Resources needs but lamentably this is made difficult because of the HIV/AIDS pandemic which among other devastating effects is short life expectancy which leads to high turnover within organisations. To reduce this catastrophe, a collaborative effort has been made by International organisations, the government and the private sector to provide measures to fight the impact of HIV/AIDS. These measures have been largely effective and include initiatives such as obtaining. Political support by leaders, engaging multiple economic sectors, educating the youth on HIV/AIDS, fighting stigmatization, enhancing poverty and improving free counselling interventions just but to mention a few. The achievements brought by these measures to date in Zimbabwe include reduction of workplace discrimination against HIV/AIDS infected people, formation of the National AIDS Control Programme by the Ministry of Health in 1987 and implementation of a mandatory 3% AIDS levy to support HIV prevention.
Antiretroviral; Discrimination; Poverty; Sexually transmitted infection; Stigma; Zimbabwe.
Congenital oesophageal atresia (COA) refers to a congenitally interrupted oesophagus. It is commonly referred to in the literature as oesophageal atresia (OA) with or without tracheo oesophageal fistula (TOF) but acquired TOF is a different entity.
We present a case of OA with TOF which was not suspected antenatally despite the presence of polyhydramnios. The baby presented with respiratory distress and excessive oral secretions at the age of 3-hours following initiation of breastfeeding. Thorascopic repair was performed on the second day of life. The pre-, intra- and post-operative course was smooth with no major challenges. There was no associated anomalies in our case following thorough systemic evaluation including brain ultrasound, abdominal ultrasound, skeletal survey, ophthalmic assessment and echocardiography.
This case demonstrates the importance of maintaining a high index of suspicion for OA when faced with a combination of respiratory distress and persistent frothy oral secretions in a newborn. The antenatal and postnatal diagnostic approaches are discussed with highlights of associated anomalies and pre-operative assessment and management
Congenital oesophageal atresia (COA); Tracheo oesophageal fistula (TOF); Oesophageal atresia (OA); Vertebral defects, anal atresia, cardiac defects, renal anomalies and limb abnormalities (VACTERL); Choanal atresia, retardation of growth, genital abnormalities,
and ear abnormalities (CHARGE).
Hookworm infection is particularly problematic for middle- to low-income countries. While treatment methods are currently available, vaccination may be the ideal intervention, as it could offer cost-effective long-term protection against infection and reinfection.
Previously established lipopeptide-based vaccine formulations, proven to be effective in an oral application, were adapted for an intranasal administration using a predicted B-cell peptide epitope derived from the hookworm Necator americanus aspartic protease-1 (Na-APR-1) protein and a universal T-helper epitope attached to two lipid moieties, Pam2Cys or lipid core peptide (LCP). The lipopeptides were encapsulated into liposomes or self-assembled into nanoparticles. The intranasal vaccine candidates were evaluated in a rodent hookworm challenge model.
The vaccine candidates were formulated to optimal sizes and charges for uptake by immune cells. However, no significant serum antibody response was elicited, and no protection was demonstrated following hookworm challenge.
In contrast to the previously reported effective oral immunization, intranasal delivery of lipopeptide-based vaccine failed to trigger significant antibody responses in mice against hookworm and had no effect on parasite numbers following challenge infection.
Giving care to a patient at the end-of-life can be a challenging experience. The responsibilities of caregiving may include executing complex physical and mental tasks, financial planning, patient care, decision-making, emotional support and coordination of care.
This mixed-methods observational study aims to identify the psychosocial and economic effects of caregiving for terminally-ill patients by carers on the Hospice Africa Uganda Kampala program. It used both quantitative and qualitative data of caregivers caring for terminally-ill patients attending Hospice Africa Uganda Kampala. Simple random sampling was conducted to select caregivers who were invited to participate in the study.
Results indicate that the majority of patients who were receiving palliative care (60.9%, 103) had been diagnosed with cancer. Most participants (62%, n=105) had spent less than one year caring for their patients, while (18%, n=31) were cared for between 1-5 years. Our results show that the responsibility of caregiving has significant effects on the psychosocial well-being of caretakers. In particular, it reduced the amount of time they spent attending social gatherings and caring for their children, their religious commitment (p<0.05), as well as their level of fatigue and exhaustion (p<0.05), and negatively impacted job finding activities.
Terminal caregiving has significant effects on the psychosocial well-being and incomes of caretakers, and their ability to find a job alongside caring for the patient. Based on these findings, it is therefore recommended that caregivers be given ongoing support to help them provide care to their own family members and patients with life limiting illnesses early in the disease trajectory.
Psychosocial; Economic effects; Caregivers; Terminally-ill; Patients.
Medication adherence in clinical trials is significantly overestimated through every phase of drug development. This can cause a reduction in statistical power, potentially resulting in incorrect conclusions regarding efficacy, safety, tolerability, and dose-response relationships, in addition to major cost overruns. Digital pill systems enable adherence measurement through an embedded ingestible sensor paired with an external receiver. An oral pharmaceutical product is over-encapsulated by a pharmaceutical-grade shell containing a biocompatible sensor. Upon exposure to gastrointestinal fluid, the shell dissolves and the sensor is activated. Medication ingestion data is transmitted via a digital signal. Clinicians and researchers use this data to track, in real time, when and if a medication was taken. These systems have demonstrated a 99.4% rate of accuracy, and have over 15-years of supporting
experience and safety data. Spurred by the accelerated adoption of technology in healthcare and in everyday life, patients have become tech-savvy. They quickly adapt to these devices, and are able to use them safely and effectively. Digital pills can be implemented in most types of studies. In early-stage trials such as pharmacokinetic and pharmacodynamic studies, or dose-finding studies, accurate information on maximum-tolerated dose levels is essential and cannot be established unless study participants are highly adherent. In later-stage pivotal trials, effective medication adherence tracking can strengthen the dataset and confidence in the study results. Significant nonadherence may generate results that do not meet statistical or clinical significance for the critical endpoints, resulting in at worst, a failed trial, or at best, the need to enroll additional patients at substantial additional cost. Most clinical trials fail to achieve statistical significance, and poor medication adherence is often an important contributor. A digital pill system can ensure the quality and integrity of adherence data, increase confidence in the overall study data, and improve clinical trial efficiency.
Multi-level group selection theory is a presently rejuvenated framework for explaining the empathic tendencies of group culture and behavior as means of beneficial natural selection utility.
The purpose here is to simply articulate the ways in which the anthropological theory of multi-level group selection overlaps with the latest psychological research on child conceptualization of equity and empathy so that a focused line of thought can be followed in subsequent research on how childhood psychology interacts with classroom environs moving forward.
The impact these studies stand to have on the broader culture of education would be largely equitable, ensuring that all students from all demographics would be encouraged by like-minded teachers to further propagate their applied learning for mutual advantage and benefit while also exciting each other about what they learn by finding shared relevant experiences and desires to make relevant connections to..
Multi-Level; Group selection; Kin selection; Empathy; Pedagogy; Pedagogical practice; Evolution; Natural selection; Classrooms; Education.
The response to the coronavirus disease-2019 (COVID-19) epidemic included biomedical and vaccine research as well as identification of COVID-19 cases, contact tracing, community health promotion and disease prevention and community vaccination. The COVID-19 vaccinations remind public health professionals and non-professionals alike of this essential public health intervention for controlling infectious diseases. Actions that seek to improve existing vaccination efforts are equally important for effective public health programming.
Secondary data analysis uses an ecological study design to examine any possible associations between the number of COVID-19 cases identified at medical facilities (facility names not identified) within a healthcare system and the number of COVID-19 vaccinations administered within the system and reflect upon the findings for public health action. A loess curve was plotted to help to identify if a curvature pattern was present in a scatter plot.
The statistical algorithm for the loess curve identified a curvature pattern. All plots showed that values became more separated in moving from left to right.
This aggregate pattern in number of COVID-19 cases and number of vaccinations administered might be present in other public health settings or healthcare systems. Four refinements were proposed to help public health decision-makers to improve vaccination efforts: explore the reasons for differences in COVID vaccination given the number of confirmed COVID cases between
facilities; provide vaccination outside traditional settings; facilitate public health and primary care partnerships for community vaccination; and address vaccine knowledge-gaps in the community and other barriers to vaccination.
COVID-19 vaccination; Refining vaccination efforts; Public health decision-makers; Public health and primary care partnerships; Ecological study; Loess curve.
Advance directives (ADs) describe individuals’ preferences for life-sustaining treatments and/or surrogate decision-makers, to help avoid unwanted, burdensome treatments at the end-of-life. However, only 36.7% of adults have completed an AD. There is growing interest in adopting a public health approach to end-of-life care, including ADs. We describe the experience of Honoring Choices Tennessee (HCT) which developed a pilot program, Advance Directives at Work in Tennessee (AD@WorkTN), to enhance AD completion by the general public workforce.
The AD@WorkTN initiative targeted adults in the Tennessee workforce by engaging human resource (HR) leaders in educational presentations. Each workshop provided resources to employers to integrate ADs into the employee orientation and benefits enrollment process. Educational materials, web tools, podcasts, AD forms, and a demonstration of how to complete an AD were
included. Participants were directed to the HCT website which contains the state advance directive documents and with detailed instructions, as well as the co-branded MyDirectives app (MYD), to securely upload completed ADs. In April 2021 a HCT sponsored PBS documentary on advance care planning was produced with statewide distribution.
Over a 2-year period, 58 workshops were conducted for 260 human resources leaders representing 958 businesses. As a result, 23 businesses have included ADs as part of the employee benefit process. Additionally, a 2-year multifaceted public outreach campaign between 2019-21 has reached 2,950 employees and 958 businesses. Approximately 81,500 Tennessee viewers have seen
the Public Broadcasting Service (PBS) documentary on advance care planning. There have been 2,954 visits to the HCT website and 411 visits to the co-branded MyDirectives site.
AD@WorkTN is a promising model to promote integration of ADs into the employee orientation and benefits enrollment processes. Enhanced discussion and completion of ADs among employed individuals and enhanced public discourse such as podcasts and television productions may encourage intergenerational conversations about end-of-life care and documentation in healthcare records.
Palliative care; Advance directives; Community outreach.
The authors consider themselves organizational and leadership developers. They have been active in the corporate world for a long time, working and consulting. Their work is based on morphological psychology, a psychological approach developed by Wilhelm Salber, that aims at understanding behavior as it is in constant state of change. It is not about measuring and explaining, but about describing and understanding how things interact and change. With its comprehensive approach in describing everyday life, morphological psychology is an excellent tool for examining and understanding corporate culture. In this book, the authors examine what constitutes leadership in the corporate work environment psychologically, how “change” is managed, and what happens between “perfection” and “explosion” in leadership.
This study was conducted using the sedimentation method to assess the prevalence and associated risk factors of bovine fasciolosis around Furda Veterinary Clinic, East Hararghe, Ethiopia.
A cross-sectional study design was conducted from October 2020 up to June 2021 to know the prevalence and its associated risk factors of bovine Fasciolosis, taking animal origin, sex, age and body condition as risk factors and standard deviation. The sedimentation technique was used for the recovery of fasciola eggs from fresh fecal.
From a total of 384 animals selected randomly and coprologically examined, 117 of them contained fasciola eggs with a 30.5% total prevalence in the study area. The prevalence of bovine fasciolosis on the basis of animal origin was highest in Gorowodo 23 (28.7%), followed by Dada 24 (30.4%), Harawa 15 (20.5), Rasa Janata 25 (33.8%), and Tirtiro 30 (38.5%). Based on the sexes of animals, the prevalence rate of 74 (32.7%) in females and 43 (27.2%) in males were obtained. While animals of different ages were recorded at 43 (29.9%) and 74 (30.8%), respectively. Whereas 44 (33.6%), 45 (28.8%), and 28 (28.9%) were found to be in poor, moderate, and good physical condition, respectively. All of the risk factors investigated (animal origin, sex, age, and body conditions) were found to be non-significantly associated with the prevalence of bovine fasciolosis (p>0.05).
This study reveals that bovine fasciolosis was a highly prevalent disease in the study area and needs immediate control and prevention by the animal health office and veterinarians working together, treating cattle with anthelmintics before and after the rainy season, and increasing owner awareness about the disease.
Coprology; Bovine; Bedeno district; Furda veterinary clinic; Prevalence; Fasciolosis; Risk factors.
The electrocardiogram (ECG) of patients with hypertrophic cardiomyopathy (HCM) ranges from normal to exhibiting evidence of ventricular hypertrophy, including pathologic Q waves and ST-T wave changes. Deep Q waves in the inferior and lateral leads are one of the classic ECG findings associated with HCM. The prevalence or frequency of this finding in pediatric HCM patients, however, is not well-established. Furthermore, other pediatric health conditions have also been associated with pathologic and non-pathologic Q waves and an awareness of those conditions is important to consider when Q waves are observed. The primary goal of this systematic review of the literature is to describe the prevalence of pathologic Q waves in the ECGs of pediatric patients with echocardiogram proven HCM. A secondary goal is to review other pediatric conditions that can present with pathologic and non-pathologic Q waves.
The databases PubMed, Web of Science, Scopus and cumulative index to nursing and allied health literature (CINAHL) were searched utilizing the preferred reporting items for systematic reviews and meta-analyses (PRISMA) format. The Rayyan systemic review software was used to screen articles for final review. The initial search (Search 1) consisted of the following terms: “dagger Q wave”, “dagger-like Q waves”, “dagger shape Q waves”. Subsequently, a broader search (Search 2) was conducted to determine if viable articles were omitted in the first search. This broader search strategy eliminated the term “HCM”. The authors then performed detailed review of the articles these two searches yielded, as well as a review of the references of these articles to find other relevant articles as well as produce a list of other pediatric conditions that may be associated with pathologic or non-pathologic Q waves.
Of the articles found via the three searches, a total of nine English language articles that specifically addressed the prevalence of pathological Q waves in pediatric HCM patients were ultimately included in our systematic review. These nine articles described a total of 845 pediatric patients with HCM. Of these, 258 (30.5%) demonstrated pathological Q waves on their electrocardiograms. The range of percentages reported for pathological Q waves was 12.5 to 66.7%. Additionally, our review found fifteen different pediatric conditions reported to be associated with pathologic or non-pathologic Q waves.
Our systematic review confirmed that pathologic Q waves are a common and early electrocardiographic finding in children with HCM and may, in fact, be the only ECG finding. In addition, our review provided an extensive list of other pediatric diseases and conditions associated with pathologic or non-pathologic Q waves on the electrocardiogram.
Hypertrophic cardiomyopathy; Q wave; Pathologic Q wave; Sudden cardiac death; Pediatric.
Demand for emergency medical services or ambulance response is situated within the context of other healthcare and social welfare services. Worldwide ambulance providers have a wide variety of services available, but many services are struggling to meet service demand. Inappropriate use of ambulance services is one of the biggest concerns globally. The burden of using the ambulance services includes transporting non-critical patients to the hospital. Misuse of the ambulance services is a serious problem that must be addressed and solved.
The purpose of this study is to evaluate the public perception of appropriate usage of ambulance services and determine the applicable role of public health to reduce the inappropriate use of an ambulance.
A cross-sectional study was conducted to collect data from the general public using an online survey. The survey contains 9 questions that evaluate the public awareness of appropriate ambulance use. Participants are people from the public within the age of 18 and above.
A total of N=97 of participants’ responses were used to analyze the data.
Complete surveys and answer data using the English language.
Uncompleted surveys, and answered with other languages.
During the online survey, a total of n=97 participants enrolled voluntarily. The majority of the residents are aware of when to and whom to call in case of a medical emergency. N=35 (36%) of the participants believe that ambulance services are misused.
The conducted study demonstrated that almost 36% of participants believed abuse of ambulance services, though there might be numerous reasons for calling ambulance unnecessary. Public health plays a vital role to reduce inappropriate ambulance calls when both ambulance services and public health are integrated into one system of care.
Public health; Ambulance services; Emergency medical services (EMS); Emergency care pathway; Misuse of ambulance services; Paramedic; Scope of public health in EMS.
In practice, between groups baseline imbalance following randomization not only opens effect estimate to bias in controlled trials, it also has certain ethical consequences. Both design and statistical approaches to ensure balanced treatment groups in prognostic factors are not without their drawbacks. This article identified potential limitations associated with design and statistical approaches for handling covariate imbalance in randomized controlled clinical trials (RCTs) and proffered solutions to them.
A careful review of literatures coupled with a robust appraisal of statistical models of methods involved in a way that compared their strength and weaknesses in trial environments, was adopted.
Stratification breaks down in small sample size trials and may not accommodate more than two stratification factors in practice. On the other hand, minimization that balances for multiple prognostic factors even in small trials is not a pure random procedure and in addition, could present with complexities in computations. Overall, either minimization or stratification factors should be included in the model for statistical adjustment. Statistically, estimate of effect by change score analysis (CSA) is susceptible to direction and magnitude of imbalance. Only analysis of covariance (ANCOVA) yields unbiased effect estimate in all trial scenarios including situations with baseline imbalance in known and unknown prognostic covariates.
Design methods for balancing covariates between groups are not without their limitations. Both direction and size of baseline imbalance also have profound consequence on effect estimate by CSA. Only ANCOVA yields unbiased treatment effect and is recommended at all trial scenarios, whether or not between groups covariate imbalance matters.
Randomization; Covariate imbalance; Stratification; Minimization; Change score analysis; ANCOVA.
Since the emergence of coronavirus disease-2019 (COVID-19) and its declaration as a global pandemic, multiple ophthalmic manifestations secondary to this infection have been reported, ranging from conjunctivitis to more serious and vision impairing manifestations. In this case report, we present a case of transient myopic shift observed after COVID-19 infection, in an ophthalmology specialty hospital in Beirut, Lebanon, with a discussion of the possible causes based on literature review.
COVID-19; SARS-COV-2; Pandemic.
Although worrisome features represent an indication to perform endoscopic ultrasound study, recent studies have showed that these conditions are not strictly related to high risk of malignancy. Pancreatic resection for worrisome imaging features often demonstrates pathology consistent with low-grade dysplasia. Worrisome features should be considered as indicators of mostly
low-grade dysplasia. High-risk stigmata are more consistent for diagnosis of malignant lesions.
Worrisome features; High-risk stigmata; Intraductal papillary mucinous neoplasm (IPMN); Pancreatic neoplasm; Pancreatic high-grade dysplasia; Pancreatic low-grade dysplasia.
Intraosseous ablation of the basivertebral nerve (BVNA) is an emerging minimally invasive treatment to relieve chronic mechanical axial low back pain associated with Modic type 1 or type 2 vertebral end-plate changes. Randomized controlled trials demonstrate improvements in pain and function sustained for up to five-years.
A 40-year-old woman presented with an eight-year history of central low back with mechanical features. There was minimal response to active physical reconditioning techniques, breast reduction surgery and chronic opioid prescription. Imaging disclosed modic type 1 vertebral end-plate changes at the L5/S1 segment. Following a positive short-term response to bilateral L5/S1 facet joint injections, the L5/S1 facets were treated with radiofrequency ablation of the L4 medial branch and L5 dorsal ramus bilaterally but with minimal benefit. BVNA at L5 and S1 was provided using a bi-pedicular bipolar radiofrequency approach (description attached).
Six-week outcomes data disclosed decreased pain intensity from 8/10 to 3/10 and improved function with a decrease of 22 points on the oswestry disability index (ODI). Measures of depression, anxiety and stress, and quality of life improved significantly. Opioid usage decreased with a weaning plan. Magnetic resonance imaging (MRI) findings demonstrated new sclerosis with surrounding bone marrow oedema of the right and left sides of the L5 and S1 vertebral bodies consistent with the BVNA treatment.
This case reports technically successful BVNA using a bipedicular approach. The early result is consistent with the published literature using the uni-pedicular approach. Follow-up plans are in place. A case series will follow. In Brief A bi-pedicular bipolar radiofrequency technique for basivertebral nerve ablation to treat vertebrogenic chronic low back pain is described, including early clinical outcomes and MRI findings.
Bipedicular; Radiofrequency; Basivertebral nerve; Vertebrogenic; Modic end-plate changes.
Carotid cavernous fistulae (CCF) are unique communication between the cavernous segment of the internal carotid artery (ICA) and the cavernous sinus. CCF are rare and result from traumatic skull base fractures (0.2-0.8%). CCF resulting from iatrogenic intradural traumatic aneurysms are not common, and they are hard to treat using a surgical approach. This report presents the case of a female patient with iatrogenic CCF, which resulted from proximal ICA injury. The CCF was successfully treated using the endovascular coil embolization. The patient has reported improvement in her vision, one-year follow-up routine has indicated
no recurrence with this technique.
Coil embolization; Traumatic cerebral pseudoaneurysm; Carotid cavernous-fistula.
Poliomyelitis is an oro-fecal vaccine preventable disease affecting mainly children under five-years-old and is prevalent in poor sanitation and hygiene environment. The World Health Organization (WHO) stressed the need for coordination between the public and the non-governmental (particularly private) sectors to increase the coverage with immunization. This study aims to assess the private sector and civil society engagement in the implementation of poliomyelitis vaccination among internally displaced people and irregular settlement in Khartoum. Specifically, the study aimed to identify the major gaps in immunization program among internally displaced people (IDP), and to determine the enablers and barriers for the private sector and civil society active engagement in the immunization program.
This cross-sectional study used both quantitative and qualitative methods. Data was collected from the health facilities mangers and the expanded program of immunization (EPI) service providers at private and civil society’s facilities in the targeted areas using a semi-structured interview guideline and a self-administered questionnaire respectively. The obtained quantitative data was coded and then analyzed using the statistical package for social science (SPSS version 21) and presented using tables. For qualitative part, all data were transcribed verbatim and analyzed using a thematic analysis, paying particular attention to axes of difference, including gender, private center and non-governmental organization.
The major gaps were the insufficient number of health facilities together with uneven distribution of the available ones, and unclear mandate of non-governmental organizations (NGOs) and private sector in EPI programme. Most of the managers complained from the lack of human resources for vaccination but stressed on the fact that training of the existing staff made the availability of the service easier. Twelve (12) out of 23 health facilities visited by the field team where in areas that do not have electricity or water supply which imposed more efforts to preserve the vaccines.
Private and civil societies were not well utilized by EPI program in Khartoum, Sudan. A clear mandate for engagement and periodic training for the service providers is highly needed.
Private sector; Civil societies; Poliomyelitis vaccination; Internally displaced people (IDP).
This study was conducted by using the protocols of standard meat inspection (visual, palpation and incision) to assess the prevalence and associated risk factors and to estimate the economic loss in cattle slaughtered at Bedeno Municipal Abattoir, Eastern Hararghe, Ethiopia.
A cross-section study design was conducted from February 2020 to November 2020, to determine the prevalence and its associated risk factors of bovine hydatidosis is taking animal origin, sex and age and body condition as risk factors.
From A total of 355 cattle examined using the protocol of standard meat inspection, 99(27.8%) of them are found positive to hydatid cysts. The prevalence of cattle hydatidosis based on animal origin was highest in older cattle 89(29.47%) than young 10(18.89%). Regarding body condition, score to significance variation was observed, as the prevalence was 41.89% for poor cattle followed by medium 24.07% and good 24.37%. Of the total 99 infected, 41(11.55%) of animals were infected in their lungs with only hydatid cysts and 24(6.76%) were infected in their liver, but the rest animals had multiple organ infections, 34(9.58%). Considering the current result, the total annual economic loss from organ condemnation and carcass weight loss due to bovine hydatidosis at Bedeno Municipal Abattoir was estimated at 6,671,803.8 Ethiopian birr (ETB).
This study reveals that cattle hydatidosis was a high prevalence diseases in the study area and needs paucity of information on control and prevention. The cattle owners to be educated and awareness programmes to be conducted about the diseases.
Municipal; Hydatidosis; Prevalence; Bovine; Abattoir, Bedeno.
Convulsion is an event that can emotionally traumatise most parents. Inadequate knowledge regarding convulsion can cause parental anxiety.
This research sought to investigate the knowledge, attitudes, concerns and practices of parents regarding convulsion in children under five-years.
The study employed a community based cross-sectional survey design. Purposive, convenient and snowball samplings were used to select the study site and enroll participants to the study. The study was conducted in Muea Community, Buea Health District in Fako Division, South West Region of Cameroon. The study participants were made up of parents of children under 5-years of age and who had witnessed convulsion in a child. Respondents who met the inclusion criteria and gave their consent to participate in the study were selected. Data was collected using a semi-structured questionnaire made up of both open and closed-ended questions. Data was collected on the knowledge, attitudes, concerns and practices of parents regarding convulsions in children. Data collected was entered using a pre-designed EpiData version 3.1 and data from open-ended questions were analysed using systematic process of thematic analysis.
A total of 100 respondents participated in the study. The study revealed that more than half of the respondents 53.7% had good knowledge on convulsion, 61.9% of the respondents had positive attitudes towards convulsion and 51.4% of parents had good practices regarding convulsion. This study also revealed that knowledge of convulsion had an association (p=0.05) with gender and marital status but was not dependent (p>0.05) on age and level of school attained.
The study concluded that even though more than half of the respondents were knowledgeable on convulsion, there is still need for proper parental education as inappropriate attitudes and practices like putting the child’s head in the toilet pit, which can lead to complications are still being practiced.
Knowledge; Convulsion; Attitudes; Concerns practices; Children under five; Parents.
Although the number of deaths of coronavirus disease-2019 (COVID-19) is decreasing over the world due to vaccination process, but appearing its new variants remain it as the remarkable challenge for health authorities.
The aim of this study is to develop a probit regression model to estimate the chance of mortality for the patients infected to COVID-19.
The contributing factors of age, symptoms and underlying diseases have been considered as independent variables as well as the clearance type of death as dependent variable have been studied for estimating the mortality rate. Patients have been divided into two categories; 1) recovered or transferred and 2) death, followed by developing a probit regression model by the well-known technique of Max likelihood method.
Data have been collected for 1015 patients tested positively to COVID-19 and subsequently received clinical treatment or intensive care.
The results revealed the model is capable of estimating the chance of mortality based on age, symptoms and underlying diseases. As implication, the health authorities ultumately can estimate the patient mortality rate prior to admission procedures in hospitals.
COVID-19; Mortality rate; Healthcare management; Probit regression; Maximum likelihood.
Leptospirosis is the most widespread and most prevalent zoonotic disease caused by Leptospira bacteria this is pathogenic Gramnegative bacteria, the disease leptospirosis a zoonotic disease of global importance. It caused by various serovars of leptospira interrogans that belong to the genus Leptospira. Besides leptospira interrogans is the most serovars like the disease occurs in nearly all mammalian species. The highest burden in low-income both found in urban and in rural environments. Rodents are known as the main reservoir animals, However, all animals are reservoir include human so leptospirosis is more common in the tropical regions rather than subtropics because of the longer survival of the organism in the environment and frequent exposure of animals and humans to contaminated environments. Direct transmission to humans by broken skin and mucous membranes exposed to the urine of infected animals. While the clinical signs of leptospirosis do not vary greatly with the species of animals include laboratory tests. Control and prevention is sanitary measures, vaccination, quarantine and rodent control are the most important control measures of the disease, require elimination of the carrier state, maintenance of environmental condition and immunization of the animal, tropical areas where warm humid conditions and alkaline or neutral soil helps leptospira survive better.
Leptospirosis; Zoonosis; Leptospira; Rodent.
The use of lead protection in patient contexts has recently come under scrutiny, with organisations moving towards ceasing its use in plain film radiography. The use of lead shielding in protecting staff in low-dose settings, such as plain film and mobile radiography,
is therefore an important aspect of practice to be reviewed. The objective of this review is to evaluate the use of lead shielding in protecting staff in plain film and mobile radiography, while also exploring the evolution of occupational doses and perceptions of lead protection. While literature is limited on the use of lead protection for staff in mobile settings, lead protection has been shown to reduce staff and adjacent patient dose from scatter. Furthermore, despite the increased frequency of medical imaging procedures in contemporary radiography, the occupational doses of medical radiation workers have reduced over time. With literature demonstrating gaps in current understandings of radiobiological mechanisms at low doses, the linear no-threshold model utilised to estimate radiation risk and develop protection standards cannot be rejected. Thus, this review finds the need for further research to be undertaken to improve risk estimates at low doses in larger cohorts of medical radiation workers, for the demonstration of long-term effects from occupational exposure, prior to ceasing staff lead protection.
Radiation protection; Occupational dose; Lead protection; Mobile radiography; Radiography; COVID-19 pandemic.
Theophylline poisoning leads to multisystem toxicity. Management of theophylline overdose is focused on stabilizing cardiovascular manifestations of arrhythmia and hypotension, correcting metabolic derangements, aborting seizures and removing the drug from the system. We present a case of refractory seizures and haemodynamic instability from theophylline poisoning and reviewed
the literature to update the management of severe theophylline overdose.
A 73-year-old Chinese gentleman presenting with chills and rigor was admitted for management of sepsis. While admitted suffered seizures which were refractory to benzodiazepine and anti-epileptic drugs. Based on his previous admission for theophylline overdose, serum levels were done confirming severe theophylline poisoning. He was resuscitated and subsequently started on haemodialysis following which seizures were eventually aborted when theophylline levels were successfully reduced.
Severe theophylline poisoning should be identified early and appropriate treatment initiated promptly. In the management of refractory hypotension, methylene blue and venoarterial-extracorporeal membrane oxygenation are reasonable rescue therapies to consider. Multi-dose activated charcoal and extracorporeal treatments for elimination of drugs should be administered in severe theophylline poisoning.
Theophylline poisoning; Theophylline-associated seizures; Haemodialysis; Case report; Methylene blue; Venoarterial-extracorporeal membrane oxygenation; Multi-dose activated charcoal.
Developmental disabilities (DDs) refer to a group of conditions that influence the early development of children and cause changes in their normal developmental pattern affecting their physical, language and mental abilities or behavior. Children with DDs just like normally developing children have health issues that need to be addressed. This special group of children especially those having autism frequently suffer from associated conditions such as gastrointestinal disorders, eating and feeding challenges, seizures, sleep disturbances, attention deficit and hyperactivity disorder, and anxiety among others. These health problems affect the health of these children in different ways and extent. Thus, children with DDs need to access healthcare services and receive quality medical care just like their normally developing peers. However, the health needs of children with DDs particularly autism are not being met as required even though this special population are more likely to seek medical care due to their disabilities and associated conditions. Children with autism and other DDs experience disparities in health and healthcare service utilization. Autism is linked to many health conditions such as epilepsy, gastrointestinal problems and other mental disorders. These health problems affect each individual with autism in a unique way negatively affecting his/her existing social interaction and communication impairments. Again, health facilities and medical equipment are not disability-friendly making it difficult for this special group to effectively have access to quality care. In addition, most healthcare providers do not possess adequate knowledge and skills required to make critical decisions regarding this very special group of persons. Furthermore, due to cultural differences certain diagnosis and treatment regarding autism and other developmental disabilities may not be welcomed. The public health sector of all nations has the duty to promote health and prevent diseases for all including persons with disabilities.
Developmental disabilities; Children with autism; Health conditions; Disparities in health;
Disparities in healthcare service utilization.
brief research report
This article presents an investigation of the defensiveness demonstrated by teens who are mandated to participate in treatment as compared to their non-mandated peers.
The data for this study was collected as part of The Substance Abuse Subtle Screening Inventory (SASSI) Institute’s third iteration of the Adolescent SASSI-A3. A total of 164 teenagers in treatment served as the dataset for the present study. All participant cases were provided by clinicians working in service settings throughout all U.S. Census Regions and serving in a variety of venues including substance use treatment, criminal justice programs, community corrections, private clinical practices, behavioral health centers, and social service organizations.
We present two brief de-identified treatment case studies, aptly demonstrating defensiveness and denial from a clinical standpoint. Additionally, we review cases demonstrating high-levels of defensiveness and denial in mandated teen clients, and ethical ways to break through that barrier to treatment engagement.
Working with teens can be extremely difficult given their rapid mood changes, intensely felt experiences and shifting states of compliance, openness and defiance. When teens are mandated for treatment, they may often feel their choices have been taken away and the counselor may be viewed as more of a power authority rather than a concerned and helping figure. Contingencies
placed on the teen as part of the mandated treatment experience are generally the primary focus, rather than addressing their underlying substance use disorder (SUD). As a result, the teen, as well as the counselor, require greater focus than just making sure those requirements are met.
Mandated treatment; Adolescent addiction; SASSI-A3; Defensiveness; Denial; Teen drug use.
Omalizumab is a recombinant humanized monoclonal antibody against immunoglobulin E (IgE). It is approved for the treatment of chronic spontaneous urticaria (CSU) in patients ≥12-years of age.
We carried out a retrospective cross-sectional study in 25 patients with CSU to evaluate the characteristics of response of CSU to omalizumab treatment.
A retrospective cross-sectional study of a convenient sample of all patients diagnosed as CSU who have been using omalizumab treatment during the study period from January 2018 to January 2020 in the Dermatology Department in King Abdulaziz Hospital, Makkah, Saudi Arabia.
A total of 25 patients have participated in this study. The average age of patients was 40-years. Majority of the patients were female (52.0%, n=15). The average duration of illness was 1.32-years. Majority of the patients (72.0%, n=18) received two courses of omalizumab treatment. Minority of patients (28.0%, n=7) received one course of omalizumab treatment which was statistically significant (p value<0.01). Number of patients who have been using oral 2nd generation antihistamine during the first course and 2nd course was (72%, n=18 out of 25) and (50%, n=9 out of 18) respectively. Number of flare-ups during 2nd course (1.72 flares up per patient, n=31 flare-ups among 18 patients) was less than the number of flares-up during 1st course (2.96 flares-up per patient, n=74 flare-ups among 25 patients) which was statistically significant (p value<0.01). Number of patients who showed no flare-ups during the 1st and 2nd course of omalizumab treatment was (16%, n=4 out of 25 patients) and (27.77%, n=5 out of
18 patients) respectively. The average intensity of flares-up during 2nd course of omalizumab treatment was less than the average intensity of flares-up during first course of omalizumab treatment as the following; during 2nd course ( 33.33%, n=6 out of 18 patients), (27.77% n=5 out of 18 patients), (11.11%, n=2 out of 18 patients) mild, moderate and severe flares-up respectively and the severity during 1st course was (40.0%, n=10 out of 25 patients), (28.0%, n=7 out of 25 patients), (16.0%, n=4 out of 25 patients) mild, moderate and severe flares-up respectively.
According to expert’s guidelines, CSU of ≥3-years would be treated with omalizumab for a minimum of one-year. In our study, in spite of the short duration of CSU (average duration was 1.32-years), the majority of patients (72.0%, n=18) received omalizumab for 1-year (two courses of omalizumab treatment) suggesting that the majority of patients with CSU in general requires omalizumab ≥1-year. Our study also showed 5 patients who were free of any flare-up and they were not using 2nd generation antihistamines suggesting that omalizumab alone as monotherapy can be effective.
Omalizumab; Urticaria; RCTs; Chronic spontaneous urticaria (CSU).
This study has the purpose of developing an epidemiological profile of children with neurodevelopmental disorders in southern Puerto Rico.
This is an exploratory study with a mixed design that was carried out in a diagnostic center located in Ponce, Puerto Rico. The population under study were children within 0-18-years-old of both sexes diagnosed with a neurodevelopmental disorder using the diagnostic and statistical manual of mental disorders (DSM-4) and DSM-5 criteria. The sample under investigation were all the children in the secondary database of children who received health services in the diagnostic center during 2016-2017. Additionally, to the data from the secondary database, a hand-writing record review was performed to obtain data related to comorbidities and family history. The bivariate and multivariate analysis evaluated the association between each neurodevelopmental disorder, and each disease reported in the family history of diseases. Also bivariate, and multivariate analysis assessed the association between each neurodevelopmental disorder, and each comorbidity reported.
Results and Conclusion
The mean age and standard deviation of the sample were 5.2±3.20, and 80.5% were males. Most of the children lived in Ponce, Puerto Rico. The sample size did not have normal distribution because the sample size was too small and selected by non-probabilistic methods. Furthermore, 88.2% of the children received a previous evaluation related to the problem, and 70.5% received treatment for the symptoms. The results revealed that neurodevelopmental disorders frequently co-occurred. Also, other comorbidities commonly co-occurred with these disorders. Mental disorders were commonly reported with autism, attention deficit and hyperactivity disorder (ADHD) and communication disorders. Autism was also linked to a family history of mental disorders.
Childhood; Neurodevelopmental disorder; Disabilities; Developmental delays.
Post-burn contracture is a known sequelae of burn injuries involving neck, axilla, elbow, and hand. There are many methods which are used as adjuvant in rehabilitation of post-burn contracture patients. The low-level laser therapy (LLLT) is one of the methods that can be used as an adjuvant in rehabilitation of joint stiffness following burns and but with very few data available from India. In this article we share our experience of using LLLT for functional rehabilitation of a patient with joint stiffness following postburn contracture.
Materials and Methods
This study was conducted in a burns centre in a tertiary care institute in South India. Informed consent and departmental ethical committee clearance were obtained prior to study. The subject was a young boy with no known co-morbidities with stiffness of metacarpophalangeal and interphalangeal joint of index and middle finger of right hand. Patient was treated with contracture release with full thickness skin graft. The patient received low-level laser therapy to induce collagenolysis and to increase the movement of the joints. Each joint received laser therapy for duration of 125-second every time for 15-minutes for 2 sessions in
a span of 4-days.
LLLT has been found to be useful in early rehabilitation of post-burn contracture patients with joint stiffness. No side effects were observed during the study.
The LLLT is an effective, safe, and non-invasive adjuvant in functional rehabilitation of our patient with joint stiffness following post-burn contracture. We suggest further study including multiple subjects and a control group for validation of the result.
Low-level laser therapy (LLLT); Post-burn contracture; Joint stiffness; Functional rehabilitation.
Urinary and bowel dysfunction is a condition that encompasses loss of bladder and bowel control which is characterized by partial or complete loss of defecation and urination. Urinary and bowel dysfunction is multifactorial and mainly caused by spinal cord injury at the lumbosacral level or more cranial. The present case report was aimed to show techniques and outcomes of colotomy to resolve constipation secondary to bowel dysfunction in a cat. A 1-year-old female cat weighing 1.3 kg was presented to Veterinary Teaching Hospital with a history of anorexia dullness, abdominal distension, and absence of defecation for the last 8-days. Clinical examination revealed stunted growth, poor body condition, very weak anal and pedal reflex, distended abdomen, dehydration, and lateral recumbency. Based on the history and clinical findings the case was diagnosed as constipation and exploratory laparotomy was indicated after sufficient stabilization. The caudal ventral midline was used to perform colotomy to remove accumulated feces. Post-operatively fluid therapy, antibiotics, laxative, and vitamins were administered accordingly. Upon 52-days follow-up; the patient was able to pass her feces completely, while urine retention and incontinence remains unresolved. Therefore, the owner was advised how to apply gentle external compression of the bladder to assist urination.
Cat; Colotomy; Constipation; Incontinence.
To determine first-year student pharmacists’ views on the opioid epidemic.
First-year pharmacy students were asked to complete an online survey to assess their views and opinions on the current opioid crisis using Likert-scale type questions.
Forty-four pharmacy students were surveyed, and all participants completed survey questions, 100% response rate. Majority of participants were female (N=34, 77.3%), with more than half of participants falling in the age range of 18-24 (N=25, 56.8%). Geographically, most of the participants home residences are in other states out of the DC, Maryland, Virginia (N=25, 56.9%). In addition, majority of participants worked before starting pharmacy school (N=42, 95.5%) and a majority had a pharmacy and health related occupations before pharmacy school (N=36; 81.9%). Most study participants reported an annual income of less than $10,000 (N=17, 38.6%) and obtained a bachelor’s degree (N=26, 59.1%). Majority of participants strongly agree that the opioid epidemic is becoming a severe crisis for society (N=42; 95.5%) and that opioid should be readily available when it is medically necessary to people (N=27; 61.4%). When asked if they know anyone personally who suffers from the opioid crisis, over three-quarter (N=34; 77.3%) said no. However, over two-third (N=29; 65.9%) of participants said that they have taken opioids in the past themselves to relieve pain. Although, almost all of them strongly agree that prescription opioids are addictive (N=42; 95.5.%); about eighty percent (N=35; 79.5%) agree that taking opioids is an effective way to alleviate severe pain.
Our results indicate that pharmacy students perceive the opioid epidemic as a crisis and despite their views that opioids are addictive and knowing someone who suffers from opioid use disorder, they believe opioids are a clinically effective way to alleviate pain.
Survey; Opioids; Epidemic; Students; Pharmacy.
letter to the editor
Objective: This study aimed to conduct an evaluation of music therapy clinical trials
worldwide, to understand what trials have been conducted and to show the chronological
changes. Additionally, we sought to clarify issues related to providing clinical trial registration
Methods: We searched the International Clinical Trials Registry Platform (ICTRP) database for
“music therapy,” and identified the disease target for each article found.
Results: A total of 150 clinical trial studies were found in the ICTRP using the term “music
therapy.” In these trials, music therapy was used for improvement of social functioning in
schizophrenia and/or serious mental disorders, anxiety and depressive symptoms, and cancer
symptoms. Twenty-five clinical trials were actively recruiting. Sixteen of the 25 trials were
registered in the United States at ClinicalTrials.gov, of which 9 trials were conducted in the US.
Seven trials were conducted in other countries such as Spain, Taiwan, and China.
Conclusion: A search for music therapy clinical trials retrieved 150 trials from the ICTRP, and
the number of clinical trial registrations has increased yearly. Music therapy is widely used in
patients with various diseases, including Alzheimer’s disease, anxiety, and arthritic pain and
has the potential to improve certain disease outcomes, but there is not enough evidence to
substantiate its efficacy. It is important to enlighten researchers and pharmaceutical companies
on the proper management of the quality of such clinical trial information, as this is an important
Intracranial hygroma is a rare and probably missed complication of epidural analgesia secondary to accidental dural breech. The patient presented had a presumed spinal cerebrospinal fluid leak with symptoms of intracranial hypotension. Unusually the patient had both an intracranial subdural hygroma and rarely reported extensive spinal intradural (extra-arachnoid) collection following a lumbar epidural, administered in labour. Given the potential for progression to symptomatic neurological deficits, anesthetists should consider subdural hygroma when encountering patients with features of intracranial hypotension, or altered neurology following epidural. Pathophysiology, imaging and management are discussed.
Subdural hygroma; Epidural; Dural puncture.
Congenital anomalies planned for ocular surgeries range from the rare to atypical to common. Many of this rare ophthalmopathy are associated with clinical syndromes and have important anesthetic implications. Not only is it important to know the syndrome we are dealing with, but it’s also the more important to understand the systems that are involved, the extent of involvement, potential anesthetic complications, right from the cerebrovascular, cardiovascular, endocrine, metabolic, neuromuscular, genitourinary systems to airway. Understanding these aspects becomes more important in rare clinical scenarios as it helps to plan the case, anticipate and treat the complications. Congenital anophthalmia is one of the rare conditions with an incidence of <3/1000 with microphthalmia reported in up to 11% of blind children, hence we report a rare case of bilateral congenital anophthalmia planned for excision of right ocular swelling.
Ophthalmopathies; Congenital anophthalmia; Microophthalmia; Ocular surgery.
Maintenance of the airway and adequate ventilation are essential for the anesthetized patient and may be compromised in patients with pan-facial trauma, abnormal dentition, abnormal mandibular space, or presence of dental hardware. We present an unusual case of a patient with a lack of natural mandibular structure and exposed mechanical hardware with fistula complicating intubation and ventilation prior to surgery.
A 35-year-old male with a history of a self-inflicted gunshot to the left submandibular region approximately 6 years prior was scheduled for urgent mandibular hardware removal, closure of left facial fistula, and removal of several teeth. Pre-oxygenation and ventilation were complicated by extruding hardware and eroded skin, causing interference with a conventional facemask seal. The patient was pre-oxygenated using the SuperNO2VA™ nasal mask with which an adequate seal was achieved without use of a nasal trumpet and with a modified grip. Tracheal intubation via oral video laryngoscopy was successful, and the case proceeded uneventfully.
Adequate ventilation and airway maintenance can be difficult to achieve in patients with abnormal facial structure or mandibular mechanical hardware using conventional methods. The SuperNO2VA™ nasal mask can address airway issues for these patients peri-operatively.
Anesthesiology; Airway management; Difficult airway; Airway devices; Difficult intubation; Ventilation; Oxygenation; Facial trauma; Mask ventilation.
Pneumocephalus is a complication seen either after head trauma or post-neurosurgical procedure. It can be life-threatening if it turns into tension pneumocephalus. The presence of intracranial air indicates the presence of an open communication of cerebrospinal fluid. Air enters dura matter even without connection. Thin air flows upstream along the cerebrospinal fluid (CSF) pathway. Herein, we report a case of pneumocephalus in a 62-year-old female after epidural injection of Bupivacaine and Ozone for the treatment of a prolapsed disc. She was shifted to our hospital post-epidural injection for the management of severe headache. Though it is a rare complication, keeping this in mind will help to quickly diagnose, if need arises.
Pneumocephalus; Head trauma; CT; Thunderclap headache.
Cancer immunotherapy has evolved enormously in the recent years with better understanding of immune reactions, immune microenvironment and immunosurveillance. Breast cancer is characterized by large heterogeneity, a fact which rather complicated the development and the approval of novel therapeutic options in comparison to the majority of other solid tumors since each subtype has required a unique scientific approach and different targets and goals. Triple negative breast cancer (TNBC) is considered the most aggressive of the breast cancer subtypes with limited treatment options and worse outcome compared to others. This article summarizes some of the early clinical studies and the recently presented phase III clinical study of immunotherapy checkpoint inhibitors in this difficult setting.
Keywords: Cancer; Immunotherapy; Triple negative breast cancer (TNBC); Breast cancer.
Postpartum haemorrhage is the leading cause of maternal mortality and morbidity. The significant impact of postpartum haemorrhage (PPH) on maternal mortality can be reduced if timely measures are implemented. Transcatheter arterial embolisation (TAE) is an alternative therapeutic strategy for PPH.
We report a case of postpartum haemorrhage which was managed by transcatheter arterial embolization in lieu of hysterectomy to preserve fertility and menstruation in a 27-year-old patient.
The critical role of obstetrician, anaesthesiologist and interventional radiologist as a team, improve the quality of care and patient safety.
Postpartum hemorrhage (PPH); Peripartum hysterectomy; Transarterial embolisation.
To study the role of sound enhancer device in teleconsultation.
This study was conducted in the plastic surgery department in a tertiary care centre in the month of May-June 2019. A sound enhancer device was used with mobile phone for videoconferencing as form of teleconsultation by plastic surgery trainees in operation theatre and outpatient department. At the end of the study feedbacks were taken from the trainees.
It was found that on using the sound enhancer device, the sound quality improved and it was helpful in the teleconsultation sessions using videoconferencing.
The use of sound enhancer is a simple, cost-effective, innovative method of using a simple technology to aid in utilisation of teleconsultation facilities in a very non-sophisticated way.
Sound enhancer device; Teleconsultation; Telemedicine.
Cervical cancer is a common cause of cancer-related deaths in women worldwide, with a fatality rate second only to breast cancer. Human papillomaviruses (HPVs) are the main causative agents of cervical cancer, and are therefore obvious targets for vaccine development. Although two prophylactic HPV vaccines have been commercialized, therapeutic vaccines against HPVs have not been developed yet. Current vaccine technologies emphasize the power of small particles in targeting immune cells, and particles of 20-50 nm have been reported to induce optimal immune responses against a variety of pathogens and cancers.
We synthesized new nanoparticle-based vaccines against cervical cancer by using antigenic 8Qmin peptide epitope derived from HPV-16 E7 protein, a hydrophilic poly-(L-glutamic acid) (PGA) linker, and an 8-arm poly (tert-butyl acrylate) dendrimer-based delivery system (D8).
Four different peptides containing 8Qmin and PGA of different lengths were successfully synthesized with high yield and purity. These were then conjugated to alkyne-functionalized D8 by copper-catalyzed alkyne-azide cycloaddition “click” reaction. The conjugates self-assembled into nanoparticles, with decreased particle size corresponding to a greater number of Glu units. The four vaccine candidates were tested in C57 black 6 (C57BL/6) mice bearing well-established (7-day-old) tumors to examine their therapeutic effects.
Interestingly, only one conjugate delayed tumor growth, and montanide adjuvanted antigen, used as a positive control, failed to demonstrate any therapeutic effect.
Peptide-based subunit vaccine; Human papillomavirus; Polyglutamic acid; Therapeutic cancer vaccine; Polymer-peptide conjugate; Self-adjuvanting; Cervical cancer.
To study the role of bactiguard infection technology (BIP) in preventing Catheter-associated urinary tract infections. This study was conducted in a tertiary care centre in the Department of Plastic Surgery, JIPMER, Pondicherry, India in the month of August 2019. The study subject was a 55-year-old gentleman with Fournier’s gangrene and type 2 diabetes mellitus (DM). The Foley’s catheter with BIP technology was used and its role in preventing urinary tract infections (UTI) was studied over a period of 10-days. During the period of the catheter use in our subject, patient did not develop features of urinary tract infections. BIP technology is claimed to be effective in preventing Catheter-associated urinary tract infections but further studies in more individuals is required to validate the same.
Bactiguard infection technology (BIP); Catheter associated urinary tract infection (CAUTI); Biofilm.
Recruitment in clinical research trials can be challenging in trials that are time-sensitive and/or are rare disease and critical care trials. One of the hurdles for recruitment in these types of clinical trials is due to the consent process, and the need to have consent of the patient within a certain timeframe, or the patient unable to consent for themselves. This paper will discuss the usage of the utilization of remote consent options for these trials.
Recruitment; e-consent; Remote consent; Clinical trials; Rare disease; Time-sensitive.
To compare the degree of bacteria dissemination using two currently available operating room (OR) personnel warming devices. The “off-label” use of 3MTM’s Bair HuggerTM vs. a fairly new device, worn around the torso and under a scrub warm-up jacket or surgical gown, the OPERATIONHEATJAC® transformer only (TRO) powered by a transformer and controlled by a 4-level controller, and best for anesthesia providers and perfusionists.
Initially, staff members in scrubs sat in a room for 3 and 6-hours with agar plates placed in various positions throughout the room. Then staff members sat in the same room under the same conditions for 3 and 6-hours, and placed the hose from 3M’s Bair Hugger under their scrubs. Agar plates were positioned in the room in the same positions as in the control. Then staff members sat in the same room under the same conditions for 3 and 6-hours, wearing the OPERATIONHEATJAC® TRO over their scrub shirt and under a scrub warm-up jacket. Agar plates were again positioned in the room in the same positions as in the control. Bacteria colony counts were compared.
The bacteria colony counts were 43.78% and 46.18% higher at 3 and 6-hours respectively from placement of the hose from 3MTM’s Bair HuggerTM under scrubs vs. the control. There was no significant difference in bacteria colony counts with using the OPERATIONHEATJAC® TRO vs. the control.
ORs are maintained cold, mostly for surgeon comfort. In an attempt to keep comfortable in this environment, peripheral OR staff opt for the “off-label” use of 3M’s Bair Hugger hose placed under scrubs. An increased spread of bacteria throughout the OR can result from this practice. Currently, there are now safer OR personnel warming devices available. In addition, this paper reviews the significance and benefits of keeping staff warm and comfortable.
Warming devices; OPERATIONHEATJAC®; surgical site infections (SSIs); Operating room (OR); Temperature.
Gemcitabine is the backbone of systemic treatment of locally advanced and metastatic intrahepatic cholangiocarcinoma. In recent literature, gemcitabine has been linked to various pulmonary side effects.
We report a case of an 82-year-old male who developed acute pulmonary hypertension after receiving one cycle of gemcitabine for metastatic cholangiocarcinoma. His symptoms began with fatigue associated with shortness of breath and cough that worsened despite dose reduction. He developed new onset bilateral pulmonary effusions and an echocardiogram revealed findings consistent with pulmonary hypertension. A computed tomography (CT) angiogram was negative for pulmonary thromboembolism. Although he was promptly treated with diuretics and steroids, the patient could not tolerate any further therapy.
Gemcitabine-induced pulmonary hypertension is rare and can be challenging to diagnose, as it remains a diagnosis of exclusion. However, physicians should be vigilant of new pulmonary symptoms, as delayed treatment can cause significant patient morbidity and mortality.
Cholangiocarcinoma; Gemcitabine; Pulmonary hypertension.
CT: Computed Tomography; PE: Pulmonary Thromboembolism; GIPT: Gemcitabine-Induced Pulmonary Toxicity.
Absorbable threads represent one of the most exciting breakthroughs in aesthetic medicine. The innovative composition of absorbable poly-L-lactic acid (PLLA)/caprolactone (PCL) threads enriched with hyaluronic acid (HA) has triggered the interest of aesthetic practitioners.
To compare the aesthetic outcomes of armouring procedures with absorbable PLLA/PCL threads versus the same procedure performed with PLLA/PCL/HA threads (APTOS, Tbilisi, Georgia threads).
Materials and Methods
Eight patients underwent thread insertion in the face (PLLA/PCL threads on one side and PLLA/PCL/HA threads on the other). Aesthetic outcome was determined subjectively by the patient after 7 days using a 5-point rating questionnaire. Wrinkles were evaluated objectively using 3D photosystem software after 7, 30, and 90 days.
Seven days after treatment there was significantly less pain, less swelling, less burning and a faster reduction of skin irregularities on the side treated with HA-enriched threads (all p<0.05). The side of the face treated with HA-enriched threads also demonstrated faster and more obvious improvement of wrinkles.
Absorbable PLLA/PCL threads have a reliable reputation for oval correction of the face and long-lasting biostimulation. The new HA-enriched threads shorten the post-procedure downtime, accelerate rejuvenation and provide more significant patient satisfaction.
Absorbable thread; Thread lifting; HA-enriched threads; Aesthetics.
The Lactobacillus is an industrially-important group of probiotic organisms that plays an important role in human health by inhibiting harmful and pathogenic bacterial growth, boosting immune function, and increasing resistance to infection. The aim of this study was to identify the probiotic bacteria Lactobacillus based on their phenotypic features and genotypic features. This study also shows the importance of probiotic bacterium, and the effects of their antibiotic resistance to human.
Six different brands were cultured on man, rogosa and sharpe (MRS) agar. The identity of the culture was based on the characteristics of the strains of Lactobacillus spp. which was characterized using their phenotypic features (cell morphology, Gram’s staining tests which are specific for Lactobacillus genus). The bacterial deoxyribonucleic acid (DNA) was extracted by two different methods, boiled cell method and cetyl trimethylammonium bromide (CTAB) method. Furthermore, the extracted DNA yields were compared to determine which gives the best yield. The bacterial genus was detected with using genus specific primers, specific to the Lactobacillus. All the isolates were further subjected to antibiotic resistance test using disc diffusion method against a total of 4 antibiotics (Erythromycin, Tetracycline, Vancomycin and Ampicillin) and the antibiotic resistant genes of tet(M) & erm(B), were analyzed by polymerase chain reaction (PCR).
Five isolates out of six samples (A to E) were found to exhibit multiple resistance against some of the most commonly used antibiotics. The isolates showed resistance toward tetracycline, erythromycin & vancomycin. Besides that, the isolates displayed a low-level of resistance toward ampicillin.
This study proves that antibiotic resistance is present in different species of probiotic strains, which may pose a food safety concern.
Lactobacillus; Probiotics; Antibiotics; Tetracycline; Vancomycin; Erythromycin; Ampicillin; Antibiotic resistance.
The American diet is nutrient-poor and rich in unhealthy compounds like sodium, sugar, and saturated fats. Whether food has an effect on appearance has not been fully elucidated. The purpose of this prospective, single-armed study was to evaluate the impact of consuming two nutrient-dense functional foods, which are low in salt, sugar, and saturated fats, on hair, skin, and fingernail health.
Both subjective (self-reported questionnaires and photographs) and objective (i.e., salivary pH and skin hydration) tests were used to evaluate appearance. Weekly compliance with nutrient-dense foods, body weight, and quality of life assessment were also recorded.
Participants(n=28) consumed most of the nutrient-dense foods and remained weight stable, which was the goal of the study to exclude the effect of changes in body weight on appearance. Neither objective measurement of appearance showed significant improvements. Subjective measurements using questionnaires specific to hair, skin, and fingernails improved significantly over the 8-week study. Rating of photographs that the participants took of themselves improved significantly over the 8-weeks. These included reduced redness, decreased pore size, and better skin color. Using an acne-rating scale, a significant improvement was observed at week 8 compared to baseline. The quality of life parameters improved significantly including feeling of well-being, feeling full, having more energy, sleeping better, having less stress, and being more focused.
Inclusion of two nutrient-rich, functional foods in the diet improved the appearance of hair, skin, and fingernails. These foods were well-received and easy-to-prepare, leading to excellent compliance with the dietary protocol.
Appearance; Diet; Functional foods; Nutrient-dense foods; Hair; Skin; Nails.
To evaluate the immunogenicity of a recombinant protein D from Haemophilus Influenzae (Hi) and the functional activities of the induced protein D antibodies in a mouse model.
Female Balb/c mice were immunised subcutaneously with recombinant protein D in the presence or absence of adjuvants and the serum immunoglobulin G (IgG) response to protein D was assessed by ELISA. The functional activity of the immune sera was evaluated in vitro using bactericidal assay against typeable Hi serotype b (Hib) and non-typeable Hi (NTHi) clinical isolates and in vivo using an infant rat bacteraemia model and a Hib clinical isolate.
A dose-dependent IgG response was induced in mice immunised with the recombinant protein D and this response was further increased by the adjuvants used [CPG, AlPO4 and Al(OH)3], with the latter showing the greatest effect on the antibody response. Immune sera were very effective in bactericidal assay against several Hib and NTHi clinical isolates, with a higher serum bactericidal titre against the NTHi than against the Hib isolates. This is possibly due to the lower expression of protein D on the Hib isolates used in our study, compared to the NTHi isolates. In addition, anti-protein D antibodies were partially protective in vivo infant rat bacteraemia model against a challenge with Hib Eagan strain.
Our results suggest that recombinant protein D is a good vaccine candidate against Hi and should be given in combination with other vaccine candidates to ensure complete protection against Hib and NTHi.
Haemophilus influenzae (Hi); Haemophilus influenzae serotype b bacteraemia; Rats.
This case report presents the diagnosis of superior mesenteric artery and nutcracker syndromes in a previously fit and well 14-year-old girl. Although these two entities usually occur in isolation, despite their related aetiology, our patient was a rare example of their occurrence together. In this case the duodenal compression of superior mesenteric artery syndrome caused intractable vomiting leading to weight loss, and her nutcracker syndrome caused severe left-sided abdominal pain and microscopic haematuria without renal compromise. Management of the superior mesenteric artery syndrome can be conservative by increasing the weight of the child which leads to improvement of retroperitoneal fat and hence the angle of the artery. The weight can be improved either by enteral feeds or parenteral nutrition. This conservative management initially helped but not in the long-term as the child started losing weight again. The next step in management is surgery (duodenojejunostomy – if the conservative management fails), which the child went through, remarkably improving their symptoms.
Unique difficulties and challenges can arise for rare diseases and orphan disease indications within a clinical trial. Some of the challenges encountered by trials that are working on rare diseases can include recruitment and enrollment. One of the explanations for the challenges that are encountered in rare disease trials is because of the trial design of study, where the investigational product is being compared to the placebo. This review paper discusses the usage of placebo and when other options could be taken into consideration while creating the protocol, specifically with consideration to rare disease studies. It is essential for the investigators and those designing the protocol to consider alternative options from the standard randomized controlled trial. The aim of this paper is to review alternative trial design options. The trial designs discussed in this review paper include crossover trials, single arm studies and historical data, and n-of-1 trials.
Recruitment; Enrollment; Placebo controlled; Clinical trials; Rare disease; Crossover trials; Single arm study;
Historical data; n-of-1 trials.
Previous literature has reported ill-effect of ototoxic drug on hearing and balance. Present study investigated awareness among medical doctors for the same.
A total of 55-medical doctors of multiple specialties from Assam, India participated in the present study. A total of 14 questions with Likert Scale based scoring pattern were framed and validated for the present study.
Outcome of the present study showed high awareness percentage about side effect ototoxic drugs was obtained, which was a satisfying outcome.
While low audiological referral and consultation awareness was identified as an area of concern.
Ototoxicity; Doctors; Assam; Awareness.
Traditionally, ciliary body destruction has been used to treat uncontrolled intraocular pressure (IOP) following maximally tolerable medical therapy. This is due to the large number of complications seen with this procedure. However, recently a new technique of sub-threshold laser or micropulse laser, is able to provide selective destruction of the ciliary body in a controlled manner. This avoids most of the complications seen with other modalities. We have performed a small case descriptive pilot study to assess the effectiveness of micropulse transscleral cyclophotocoagulation (MP-TSCPC) in lowering IOP.
This pilot study was conducted on four patients in the age range 55-70-years with intractable glaucoma. Two patients had primary angle closure glaucoma, one-each had steroid-induced glaucoma and neovascular glaucoma. Mean baseline IOP was 32±2.4 mmHg. Mean number of glaucoma medications were 2.5±1.5. All patients underwent 180° MP-TSCPC. Absolute success was defined as IOP<20 mmHg without acetazolamide.
Following the procedure the patients were followed-up at days 1,7,30 and 90. At the last follow-up of the study, mean IOP was 18.2±1.2 mmHg in all four patients. Mild anterior chamber inflammation was the only complication noted. Mean number of glaucoma medications reduced to 1.5±1.0 following the procedure. Thus, absolute success was achieved in all patients.
This small pilot study validates other studies which show effectiveness of MP-TSCPC as an efficient and safe procedure to lower IOP. This procedure can be used over a wide variety of cases, though the indications for such procedures are still evolving. More extensive and long-term studies will clarify the position of this procedure in our glaucoma management practices.
Glaucoma; Micropulse laser; Cyclophotocoagulation.
Malrotation of the gut is rare in adults. We discuss the case of a 30-year-old primiparous woman who presented to the acute gynecology ward at 19-weeks’ gestation with ongoing nausea and vomiting throughout pregnancy. She attended on a number of occasions with the same symptoms and was trialed on a number of different antiemetics. Initial biochemical investigations were unremarkable, however, the patient started to develop signs of ‘abdominal obstruction’. A magnetic resonance image (MRI) of the pelvis showed evidence of duodenal obstruction secondary to malrotation which may be secondary to a fibrous (Ladd’s) band. She was treated laparoscopically via a Ladd procedure and had an uneventful recovery. Interestingly, the patient presented again in her second pregnancy with very similar symptoms and underwent another Ladd procedure, but via a laparotomy. This is an interesting, rare and unusual case of nausea and vomiting in pregnancy.
Ladd bands; Pregnancy; Nausea; Vomiting; Hyperemesis; Volvulus.
It was previously reported that diethylnitrosamine (DEN) enhanced liver cancer progression in ATT-MYC mouse model of liver cancer. Radiogenomics is a new tool in advanced science technology that gives information on tumor biology, non-tumor surrounding tissue, the degree of tumor size and presence of necrosis of cells especially with joined micro computed tomography – positron emission tomographys (CT/PETs).
To evaluate the correlation of gene expression and non-invasive microPET information of the liver tumors at different points of the stage of growth.
Exon array expression of the liver of ATT-MYC mice treated with DEN or butylated hydroxytoluene (BHT) compared to control non-transgenic mice were analyzed by array track and the current data were also compared to microarray expression of liver tumor of ATT-MYC mice.
The expression of genes responsible for glucose transport such as glut1, 3, 4, hk1, slc1a5, slc1a1, slc1a4, slc1a2, gp6c and gpc-1-3-4 were up-regulated significantly in DEN-treated transgenic mice immediately after end of treatment (p≤0.05), while glut2 (fold change 0.9503, p-value 0.4385) and hk2 (fold change 3.0589, p-value 0.0565) genes were increased not significantly immediately after end of treatment. Additionally, at 4.5-months of observation after the end of treatment slc1a5, slc38a2, glut1, glut4 and gpc3-4 genes had a significant fold change in liver tumor tissue in DEN treated mice when compared to BHT or control transgenic or non-transgenic one. While hk1, 2, slc5a1, slc1a4, glut2, glut3, g6pc and gpc-1 genes were increased non-significantly in the liver of treated mice when compared to control group at 4.5-months of observation after the end of treatment. Notably, c-myc, hif-1 and aldoa glycolytic genes were expressed significantly both time points of 4 and 8.5-months while ldhb, hk-2 and PKM2 were increased non-significantly in DEN treatment when compared to BHT/control non-transgenic animals.
There is a definitive correlation between genes responsible for glucose transport and 18F-Fluorodeoxyglucose (FDG) uptake in the early and advanced degree of liver carcinogenesis. This study of glucose pathway in Hepatocellular carcinoma (HCC) at different stages of early and advanced one is the potential for therapeutic anticancer therapy.
18-FFluorodeoxyglucose (FDG); MicroPET; Exon array expression; Hepatocellular carcinoma (HCC); Att-myc transgenic mice; Diethylnitrosamine (DEN), Butylated hydroxytoluene (BHT); Glucose metabolism.
Statins are widely used in the management or inhibition of several processes that lead to the development of cardiovascular diseases. Increased statin therapy has been related to the induction of type II diabetes (DM), a state which predisposes to cardiovascular disease (CVD). Statins are well-known to possess anti-inflammatory properties and the ability to disrupt de novo biosynthesis of cholesterol and lipid homeostasis has been implicated in the induction of inflammatory responses within pancreatic β-cells. Inhibition of β-hydroxy β-methyl glutaryl-CoA (HMG-CoA) results an increased level of low-density lipoproteins (LDL) receptors. Increased LDL receptor numbers will replenish exhausted intracellular supplies, resulting in higher levels of intracellular cholesterol. Therefore, stimulating immunological response and inflammatory reactions, disrupt the functional integrity of the β-cell via oxidation of the plasma-derived low-density lipoprotein. Despite the pleiotropic effects of statins on the pancreatic β-cell, they have also been reported to affect a number of other cell types associated with the development of diabetes. Inhibition of the biosynthesis of isoprenoid by statins has been associated with the down-stream regulation of glucose transporter (GLUT 4) in adipose tissues, which facilitates the uptake of glucose. This effect resulted in increasing resistance to insulin in the liver, muscle, and adipose tissue. Adiponectin, a plasma protein released by adipocytes, alters fatty acids and carbohydrate metabolism both in the muscle cells and liver. This process indirectly influences resistance to insulin by the attendant decrease in hepatic gluconeogenesis and to upregulate muscular β-oxidation and glucose uptake.
The aim of this prospective study is clinical and ultrasonographic evaluation of the pelvic floor in primiparous women after normal vaginal delivery with episiotomy and without episiotomy.
This is a cross-section study of primiparous women with a history of delivery at Tanta University Hospital from August 2018 to August 2019. The sample power was calculated based on avulsion (major and minor) in two groups (vaginal delivery with episiotomy and without episiotomy) of total forty-primiparous women with an interval after delivery (20 cases after normal vaginal delivery with episiotomy and 20 cases after normal vaginal delivery without episiotomy).
Twenty-four hours of delivery there was a highly significant difference between group A (with episiotomy) and group B (without episiotomy) regarding to ultrasound abnormalities, degree of tear, blood loss, hemoglobin concentration and clinical findings, while no difference regarding levator ani weakness. Two months later from delivery there was no significant difference between group A and group B regarding to ultrasound abnormalities and levator ani weakness while there was a difference between the two groups in regarding with clinical findings.
Normal vaginal delivery without episiotomy in primiparous women is better than normal vaginal delivery with episiotomy as there is no perineal tenderness, no dyspareunia. Low incidence of urinary, rectal incontinence, tear and perineal infection.
Clinical and ultrasonography; Primiparous; Normal vaginal delivery; Episiotomy.
Current image reconstruction techniques in computed tomography (CT) such as filtered back-projection (FBP) and iterative reconstruction (IR) have limited use in low-dose CT imaging due to poor image quality and reconstruction times not fit for clinical implementation. Hence, with the increasing need for radiation dose reductions in CT, the use of artificial intelligence (AI) in image reconstruction has been an area of growing interest.
The aim of this review is to examine the use of AI in CT image reconstruction and its effectiveness in enabling further dose reductions through improvements in image quality of low-dose CT images.
A review of the literature from 2016 to 2020 was conducted using the databases Scopus, Ovid MEDLINE, and PubMed. A subsequent search of several well-known journals was performed to obtain additional information. After careful assessment, articles were excluded if they were not obtainable from the databases or not available in English.
This review found that deep learning-based algorithms demonstrate promising results in improving the image quality of low-dose images through noise suppression, artefact reduction, and structure preservation in addition to optimising IR methods.
In conclusion, with the two AI-based CT systems currently in clinical use showing favourable benefits, it is expected that AI algorithms will continue to proliferate and enable significant dose reductions in CT imaging.
Computed tomography (CT); Artificial Intelligence (AI); Image reconstruction (IN); Machine learning (ML); Deep learning (DL); Dose reduction.
AI: Artificial intelligence; CT: Computed tomography; ML: Machine learning; DL: Deep learning; FBP: Filtered back-projection; IR: Iterative reconstruction; MBIR: Model-based iterative reconstruction; LDCT: Low-dose computed tomography; FDA: U.S Food and Drug Administration; ANN: Artificial neural network; DNN: Deep neural network; CNN: Convolutional neural network; CNR: Contrast-to-noise ratio; SNR: Signal-to-noise ratio.
India is a vast country with limited human resources. People living in remote areas often have limited access to healthcare facilities. To address this need and to increase healthcare awareness, health camps have been established. These camps are often supervised by junior physicians. Telemedicine, and in particular use of a digital stethoscope may provide better diagnosis and better consultation to the patient by senior physicians located remotely. This article highlights the clinical use of a digital stethoscope in such a health camp.
Health camp; Telemedicine; Digital stethoscope.
Patient centricity has led to the idea that drugs should answer medical needs not only defined by the medical bodies but relevant for the patients themselves. This implies that the diversity of the patients should be represented in clinical trials. Disparities in representation of diverse populations in clinical trials have been well-documented for several pathologies like arterial hypertension, diabetes but also in oncology. Today, Caucasian patients included in clinical trials represent at least 75% of the clinical trials population even in pathologies where minorities are largely more affected than Caucasians. Filling the gap in diversity is an important matter to ensure ethics, good practices, regulatory compliance, patient safety and scientific validity. To achieve their recruitment goals and being patient centric, sponsors and investigational sites need to pay attention of this problem and put in place specific strategies. Mistrust of patients of minority groups toward clinical research is one of the main barriers along with lack of access to clinical trials (low awareness, communication barriers, distance to investigational sites). Adapted communication, community-based strategies are some of the useful strategies directed to the patients. Investigators may not encounter diverse populations in their area or may not be aware of unconscious bias when identifying patients suitable for a clinical trial. Looking for referrals and raising awareness of the risk of bias with training on culturally sounded approaches could help investigators to recruit more diverse populations. Lack of awareness and costs may prevent sponsors to focus on diversity but ethics, benefits of data acquisition and patient centricity should be enough motivators to modify this trend. Patients, investigators and sponsors have their own barriers to tackle the lack of diversity in clinical trials. The cultural background of all stakeholders is an important factor in those barriers. Only multidisciplinary approaches including human sciences would help to define patient recruitment strategies that would mitigate the current lack of diversity.
Clinical trials; Patient recruitment; Diversity, Minorities.
Agenesis of the thyroid isthmus is a rare entity with a incidence rate of 0.5 and 10%. Thyroid isthmus agenesis could be associated with ectopic thyroid tissue or agenesis of the thyroid lobes. We discuss a case of a multinodular goitre which presented with morphological variations which was not detected on ultrasonography of the neck.
Thyroid; Head and neck; Isthmus.
The coronavirus disease-2019 (COVID-19) emergency has clearly shown the need to discover, test and produce a new vaccine but also in general the fragility of the current chain of clinical trials. Through this emergency, is it possible to look at the current clinical trial processes with new eyes? Is it possible to seize the opportunity for change and to have confidence in the possibility of their improvement? In this short article the authors wanted to give an optimistic answer to this question by pushing on the possibilities of innovation nowadays.
Clinical trials; Innovation; Covid-19; Digital transformation.
Hackensack Meridian Health, a large New Jersey network comprised of 17 hospitals, a medical school, and 200 ambulatory care centers, executes a large research program with approximately 1000 active human subjects studies. With the arrival of the coronavirus disease-2019 (COVID-19) pandemic, the Office of Research Administration was confronted with a series of challenges. These included minimizing face-to-face contact among research participants and staff, allocating limited resources to handle the influx of COVID-19 related proposals, providing human subjects protection training to the physicians and staff who were needed to run the clinical trials, adjusting bio-repository activities to meet the increased demand for samples, and disseminating all of the new regulatory and operational information to the thousands of researchers in the network. The network’s success in modifying its research program quickly and effectively to adapt to the changing landscape can be attributed, in large part, to the centralized nature of the research administration.
Research administration; COVID-19; Network.
Monitoring adherence to pre-exposure prophylaxis is a critical component of reaching ending the human immunodeficiency virus infection (HIV) epidemic goals in the US. Currently, providers still depend on “self-report” pre-exposure prophylaxis (PrEP) adherence, whereby providers ask their patients about their recent pill taking habits. There appears to be growing consensus across the HIV prevention community that “self-report” is an inadequate method of identifying that is in-need of additional adherence support services. In a recent survey, 97% of providers report utilizing self-reported adherence because it is convenient, but only 10% of these providers believe it is accurate. While “self-report” is convenient, evidence and testimonials from diverse stakeholders across the HIV prevention landscape indicate that there is a desire for more accurate, effective adherence monitoring methods. In this mini-review, we will briefly synthesize the emerging evidence and propose a solution to ensure all patients receive the support needed to protect them from HIV acquisition.
Pre-exposure prophylaxis; HIV; Adherence; Prevention; Self-report.
Although the negative pressure wound therapy (NPWT) is a time tested method of wound preparation, the role of NPWT with instillation and dwell time (NPWTi-d) in decreasing the downtime of wound preparation needs to be evaluated.
The objective of this study is assess the role of NPWTi-d in wound bed preparation.
Materials and Methods This study was conducted in a tertiary care center, after getting informed consent and ethical clearance. NPWTi-d was done on a 36-years-old female with no known co-morbidities admitted with infected raw area over the right below knee amputation stump and exposed bone who was not responding well to conventional wound dressing. NPWT was applied with the help of sterile polyurethane sponge and two tubes. The antimicrobial solution used was ionic silver solution, just enough to wet the sponge completely and up to the point when the transparent occlusive covering begins to lift. Negative pressure was applied at 125 mmHg. The wound was bathed with ionic silver solution and it was allowed to stay in the wound for 10-minutes, after every 2-hours of negative pressure application. This was continued for 1-week. The dressing was opened at the end of 1-week, wound irrigated with normal saline, exudate swabs for culture taken and debrided, following which fresh NPWTi-d was applied. This was repeated for the next 3-weeks.
By the end of third week, the wound became clean, fully covered with healthy granulation and the wound bed was ready to undergo the definitive wound cover procedure.
Negative pressure wound therapy (NPWT); Negative pressure wound therapy with instillation dwell time (NPWTi-d); Ionic silver solution; Wound bed preparation; Amputation stump.
A clinical study was conducted to evaluate fingerstick blood as a viable biological matrix for monitoring prescription and illicit drugs in a clinical setting on patients undergoing pain and addiction treatment. The current standard for monitoring patients’ medication use, misuse, and diversion is urine drug testing (UDT).
This study compared 632 paired urine and fingerstick blood specimens collected at three pain management clinics and one suboxone clinic for 35 drugs and/or metabolites. Plasma from the fingerstick blood was used for the analysis. The urine and plasma specimens were analyzed by validated liquid chromatography–tandem mass spectrometry (LC-MS-MS) procedures. The urine cutoff used by most pain testing laboratories were used to identify positive and negative drugs in urine. Limit of quantitation was used to identify positive and negative drugs in plasma. Drugs and/or metabolites were quantified in both urine and plasma using deuterium-labeled internal standards.
Results were tabulated for urine and plasma specimens for data analysis. The results showed that 8.7% of plasma specimens detected more drugs compared to the corresponding urine specimens, and 2.2% of the urine specimens detected a drug that was negative in the corresponding plasma specimen. Overall 89.1% of the specimens had complete agreement between urine and plasma specimens for detection. The observed Cohen’s Kappa value for overall drug detection was 0.96 an “almost perfect” agreement as characterized by Landis and Koch.
Based on the observed data, the authors conclude that plasma collected from fingerstick blood is a better matrix to monitor patients currently prescribed pain medications or patients currently undergoing medication-assisted opioid treatment compared to urine drug testing.
Fingerstick blood; Pain management; Prescription drugs; Opioids; Opiates; Illicit drugs.
Liposomes have been used for drug delivery since their discovery 60-years-ago. The advantages they provide as carriers have been recognised and exploited to improve the delivery of numerous drugs and eliminate harmful side-effects. Liposomal delivery has been tested for anticancer drugs, anti-tuberculosis drugs, variety of vaccines, just to list a few.
We developed a series of liposomal formulations with the addition of cholesterol and polyethylene glycol. The uptake of these formulations by human epithelial prostate cancer (PC-3) cells and mouse macrophages was examined and analysed by flow cytometry and confocal microscopy.
Among the liposomes tested, small anionic liposome vesicles (≤200 nm) prepared with egg phosphatidylglycerol as the main lipid were most effectively taken up by PC-3 cells and macrophages.
We produced a liposome formulation that can be used as a model system for the delivery of drugs and vaccines.
Liposomes; Drug delivery; Vaccines delivery; Egg phosphatidylglycerol; Polyethylene glycol.
Medical and psychological literature finds that empathy is crucial in the doctor-patient relationship, and that in the last 30-years there has been a decrease among college students, particularly medical students. After the passing of Hurricane María in Puerto Rico, many medical professionals migrated, leaving the island with fewer specialists to teach the remaining medical community. This is the first such study conducted with medical students in Puerto Rico. It examines the perception of empathy from the medical student perspective amidst the particular historical context of a national emergency.
Three instruments were used: The Jefferson Scale of Empathy (Student Spanish Version) (JSE-S), Arrogance Scale (AS) and Social Desirability Scale. A Non-Experimental Correlational Exploratory study was carried out with 200 medical students (55.5% female; 44.5% male), who were coursing third (45.5%) or fourth year (54.5%), from three major medical schools on the island. The students signed informed consents and also answered sociodemographic questions.
The JSE-S demonstrated an acceptable internal consistency reliability (α=0.79) with 11 items and three underlying factors. Female students showed higher empathy scores than their male counterparts (M=73.96 vs. M=70.22, p=0.001). The JSE-S and the AS were inversely correlated. Results support that social desirability is not statistically significant as a moderator between empathy and arrogance. Significant differences were found on arrogance scores pertaining to medical specialty and on religious background. Empathy and arrogance were unrelated to age, coursing year, income or university of precedence.
Raising awareness about the importance of empathy through positive role modeling, interpersonal dynamics and valuing the doctor-patient relationship through the formative years of medical school is recommended.
Empathy; Jefferson Scale of Empathy; Medical students; Puerto Rico; Arrogance; Social desirability.
To examine the role of the Identafi® device in early diagnosis of the nature of oral lesions.
Buccal mucosal lesions that diagnosed Kreatosis were the most seem lesion in oral area.
It has been observed that the indentative device provides convenience to the physician in the early diagnosis of precancerous oral
lesions and some tissue formations that may be overlooked can be reached.
Identafi®; Oral lesion; Precancerous; Early diagnosis; Tobacco; Alcohol.
This article examines one key aspect of the Substance Abuse Subtle Screening Inventory (SASSI) Institute’s forthcoming third iteration of the Adolescent Substance Abuse Subtle Screening Inventory (SASSI-A3). Overall project aims were to revise the second version of the adolescent SASSI (SASSI-A2), and to update new symptom-related identifiers of substance use disorders in adolescents according to the diagnostic and statistical manual of mental disorders, Fifth Edition (DSM-5) guidelines.
We added new questions regarding cannabidiol (CBD) edible consumption and the extent of vaping to review and subsequently address these dangers in teens. Identifying these patterns will inevitably direct the course of subsequent clinical interviews and treatment planning. Early intervention is a critical component towards preventing possible negative outcomes for substance misusing teens.
This aspect of the research demonstrated a connection between a higher acknowledged usage pattern of teens in treatment versus teens not in treatment. Correlations between beliefs associated with marijuana legalization, marijuana usage by family and friends, tobacco use, connection between age at first use, and the onset of regular usage patterns were also shown to be significantly higher among teens in treatment.
Teens that begin using alcohol, drugs, and tobacco early in adolescence are more likely to engage in vaping and edible usage. They are also more likely to use at a more frequent rate. In addition, teens who are surrounded by family and friends who engage in marijuana use are more likely to be supportive of its recreational use and legalization. This acknowledged information on the SASSI-A3 can help direct treatment planning early in the counseling relationship and provide a gateway for bringing family in the treatment and education process.
Adolescents; Vaping; Edibles; Tobacco; Marijuana; Cannabis.
This study analysed the sensitivity of the field size from variations in the target volume dimensions, depth, and position. The variations in the target volume analysis were used to determine the width of the field size. Thus, the quality control of the radiation beam can be obtained.
The computed tomography (CT) image of the IBA Dose 1 type of water phantom consists of 350 slices. Variations in the dimension of the target volume were modelled in 10×10×10 cm3, 10×12×10 cm3, 10.2×10×10.2 cm3, and 15×15×15 cm3. Beam parameters use one beam of irradiation on the central axis 0°, 6 MV energy, 100 cm source-skin distance (SSD), beamlet delta x, and y set to 0.1 cm. Dose distribution in the form of the XZ isodose curve and dose profile was used to observe the field size.
In this study, the isodose curve was successfully displayed in the XZ isodose curve. The field size’s sensitivity has been successfully reviewed from variations of the target volume, depth, and position. The target X and Z direction analysis is used in determining the width and length of the field size.
The analysis related to the field size sensitivity study was obtained from a relatively valid calculation. The field size was evaluated with variations in depth of 1.5 cm, 5 cm, 10 cm, and variations in positions of 10 cm, 12 cm, 14 cm, 18 cm, and 20 cm. This study will be used as a reference to validate the distribution of computational environment for radiotherapy research (CERR) dose in the future. Thus, the accuracy of the dose calculation can be obtained.
2D Dose Distribution; Sensitivity; Quality control; Treatment planning system; Radiation therapy dosimetry.
Merkel cell carcinoma (MCC) in an uncommon neuroendocrine neoplasia that originates in the skin in which testicular metastasis is atypical. There are only eight cases reported to date. A 65-year-old patient with a history of MCC in the right thigh who had been treated in 2015 with surgery, chemotherapy and radiation therapy; presented to hospital with pain and right testicular enlargement of one-month duration and with normal testicular tumor markers. An ultrasound study confirmed multiple hypoechoic nodular solid lesions compatible with neoplasia and orchiectomy was subsequently performed. The histological examination reported an immunohistochemical pattern compatible with a diagnosis of MCC. The patient received adjuvant immunotherapy with Avelumab. MCC rarely spreads to the testicle and, due to the shortage of studies, the best treatment of testicular metastasis remains uncertain; however, immunotherapy may be appropriate.
Merkel; Testicular metastasis.
Arterial embolization is used as one of the palliative procedure in the control of bleeding. We have demonstrated this procedure to be effective in the control of the bleeding in various malignancies in our center. This is our first case report in a teenaged nasopharyngeal cancer patient who had exhausted all his treatment as he had progressive disease and recurrent bleeding episodes from the recurrent neck nodal mass. This was controlled well with arterial embolization with no significant side effects.
Nasopharyngeal cancer; Recurrent nodal bleeding; Embolization.
Cystic lymphangioma is a relatively frequent condition. However, the scrotum is one of the least common sites. The diagnosis is made with ultrasonography and the treatment of limited and circumscribed cases, is surgical excision or sclerotherapy where appropriate. We report the case of a 23-year-old boy who presented with asymptomatic scrotal vesicular lesions evolving over 6-years. Clinical and dermoscopic examination supported by ultrasound and histology were in favor of a microcystic lymphangioma.
Cystic Lymphangioma; Circumscriptum; Scrotum; Clinic; Dermoscopy.
Caesarean section (CS) rates have increased globally. The World Health Organization (WHO) recommends the use of the Ten-Group Robson classification as the global standard for assessing appropriateness of CS. Nepal has higher-than-global average rates of CS requiring further investigation into appropriateness.
This study aims to investigate the caesarean section rates at tertiary care center in Nepal and make analysis based on the group-10 classification.
A retrospective cross-sectional study was carried out from 2016 April -2017 March in Lumbini Zonal Hospital, Butwal, Rupendehi, Nepal. 3,817 women who birth over a 12-month period were analyzed using this classification. The caesarean rate, its indications were calculated and categorized into groups according to Robson’s 10-group classification.
Women with previous CS (Group 5) comprise the largest proportion (9.4%) of the overall 26.41% CS rate. The second largest contributor was a singleton nulliparous woman with cephalic presentation at term (6.6% of total 26.41%). Caesarean section rates in single breech pregnancies were very high (>65%). Robson’s Group 5 was the highest contributors to overall CS rate contributing 35% of all C-sections, followed by Group 2 (24%), and Group 1 (13%).
The ten-group classification helped to identify the main groups of the subjects who contribute the most to the overall caesarean section rate. This study results suggest that women with previous CS are at risk for having another CS delivery in subsequent pregnancies and therefore there is an urgent need for a dedicated vaginal birth after caesarean section (VBAC) clinic to support this such women to ensure CS are only done when indicated. Furthermore, reducing the CS rate for nulliparous i.e. Group 1 and 2 would, in the long-term, also reduce the size of Group 5 in the future.
Cesarean rate; Caesarean section; Robson’s group classification.
Patients with maxillary Kennedy Class I are frequent visitors to the dental office, the missing of posterior teeth makes the control of the movement of removable partial dentures difficult due to the axis of rotation and the different resiliencies between the supporting structures. The use of implants in association to the conventional metal frame denture provides favorable long-term stability and retention, good clinical outcomes in terms of occurrence of complications and maintenance. In this clinical case, a patient with a maxillary Kennedy Class I was rehabilitated using a 3 implants to support metallic removable partial denture. A three dimensional (3D) surgical guide was used for the well-placement of the strategic implants and ball attachments were tightened as connectors between implant and denture. The patient was satisfied after 4-years of follow-up and reported good occlusal stability, esthetic and functional satisfaction.
Dental implant; Distal extension removable partial denture; Kennedy Class I; Attachment denture.
Fluid overload is a major contributor to mortality in critically ill patients but is difficult to estimate clinically. Bioimpedance has been used to estimate fluid volumes with three different methods of analysis:1. single-frequency; 2. multi-frequency; 3. bioimpedance spectroscopy. The aim of this study is to assess the accuracy of different types of bioimpedance analysis in detecting changes in fluid volumes.
Prospective observational study, in end-stage renal disease patients requiring dialysis, in a tertiary care center. During hemodialysis, we assessed the correlation between change in estimated total body water volumes, as measured by all three methods of bioimpedance, and fluid volumes removed, as measured by changes in body weight.
Twenty-four pediatric and adult patients were included in the study (median age 42.4 years) with a total of 30 study assessments performed. There was a weak correlation between change in body weight and change in estimated total body water volumes (R=0.15, 0.41, and 0.38, respectively). In the Bland-Altman analysis, the mean biases along with their associated 95% confidence limits of agreement were -0.23 L (-4.1 to 3.5 L) for single-frequency; -1.1 L (-4.1 to 1.9 L) for multi-frequency; and -0.6 L (-6.1 to 4.8 L) for bioimpedance spectroscopy.
In this study of end-stage renal disease patients requiring dialysis, the accuracy of bioimpedance measurement to evaluate fluid changes was poor, regardless of bioimpedance modality.
Body composition/physiology; Body fluid/physiology; Electric impedance; Extracellular fluid/metabolism; Renal dialysis.
A 59-year-old male presented with haematuria and was diagnosed with pleomorphic giant cell carcinoma of the urinary bladder, a very rare variant of urothelial carcinoma. The tumour was staged at pT2N3M1 and the primary tumour was removed by transurethral resection, and nodal metastases were treated with the standard systemic cisplatin and gemcitabine for urothelial cell carcinoma of the bladder. This treatment rendered the tumour clinically undetectable. Despite this treatment the patient developed brain metastases which were not found until the patient presented with neurological symptoms. This is the first recorded case of brain metastases from pleomorphic giant cell carcinoma of the urinary bladder recorded in the literature. CT imaging of the brain should be considered in the follow-up in patients with this tumour.
Urinary bladder; Brain metastases despite; Cisplatin and gemcitabine.
To read the digital imaging and communications in medicine (DICOM) images of brain and extract intensity values and build a three dimensional model for Monte Carlo n-particle transport (MCNP) code input file in purpose to study the average particle flux and deposited energy of X-Ray photons resulting at 120 kVp and 1 mAs (form point source) as function to DICOM pixel numbers in the brain tissues for a 29-year-old female patient using MCNP code and Matlab program to read the DICOM images.
The matrix laboratory (MATLAB) program was used to read the DICOM images and extract the intensity values in each pixel of the DICOM image corresponding to certain slice of the brain. These color levels are characteristic of different tissue, and have been relied upon to create the specific material in each volume element in MCNP input file.
Values of the deposited energy at surface of skin are high, so it is always necessary to be cautious when performing the examination to obtain acceptable images from the first time and without having to repeat the imaging again for the same case unless there are necessities for it.
Computed tomography (CT); X-ray; Voxel phantom; MCNP Code; Average particle flux; Matlab.
Decontamination is a critical medical counter measure in reducing toxic exposure following poisoning. Little is known on the effectiveness of this procedure and its impact in the context of preventing secondary exposure of healthcare workers and secondary contamination of facilities. Presented here is a case of dimethoate poisoning that required a prolonged period of skin decontamination to remove residual skin contamination.
A young gardener consumed dimethoate at the workplace witnessed by a colleague who called the emergency services immediately. Paramedics noted the patient to be drowsy with stable vital signs and 100% oxygen saturation. En-route to the hospital the patient vomited multiple times and was drenched in vomitus with a pungent odour. Upon arrival at the emergency department (ED), vital signs remained stable with a Glasgow Coma Scale (GCS) of 10. Due to gross external contamination from the vomitus and pungent odours emanating suggestive of chemical fumes off-gassing, the hospital decontamination shower was activated for patient decontamination. Staff donned protective suits and proceeded to disrobe and bag all the patient’s clothing before showering the patient for 10-minutes using soap and water. Post-decontamination a chemical agent monitor (CAM) were used to screen for residual chemicals following the hospital’s decontamination protocol. The chemical alarm was triggered twice, first around the left mastoid region and again just below the left breast. This required targeted re-showering for a further 10-minutes before patient was finally cleared of contamination. Subsequently, the patient was given atropine (2.4 mg) and pralidoxime (1 g) followed by an infusion at the intensive care unit (ICU). The patient made an uneventful recovery and was discharged 5-days later.
This case of dimethoate poisoning is notable for the prolonged period of skin decontamination to remove residual skin contamination and illustrates potential implications to patient and health care worker safety. Past mass casualty incidents involving
chemicals, such as the sarin attack in Tokyo, highlight the high incidence of secondary exposures amongst healthcare workers due to the lack of casualty decontamination. As a result, many hospitals have developed capacity to conduct rapid and timely decontamination at their premises to prevent further complications from secondary chemical exposure. However, the effectiveness of this process of decontamination needs further evaluation.
Contaminated casualty; Decontamination; Dimethoate; Poisoning; Hazardous material incident; Organophosphorus compounds.
In the realm of competitive athletics, numerous variables have been examined for predictive utility with respect to player selection/development and outcomes on the field. Notwithstanding important advances, the current predictors only account for a modest amount of variance in outcomes of relevance in the National Football League (NFL).
The primary objective of this study was to investigate the predictive validity of a new measure of athletic intelligence, the Athletic Intelligence Quotient (AIQ), which is based on the empirically supported Cattell-Horn-Carroll (CHC) Theory of Intelligence. The predictive validity of the AIQ was determined in relation to performance metrics from 146 NFL players across several seasons.
Hierarchical regression analyses indicate that specific AIQ factors accounted for a statistically significant increase in the explanation of variance beyond the current level of evaluation for several performance metrics (e.g., career approximate value; sacks, tackles, rushing yards). Further, specific factors of the AIQ are related to position specific statistics, offering the possibility that performance prediction can be focused in for the specific skills required by a given position.
Given the recent impact of analytics in professional sports, and the significant findings noted in the current investigation, the authors discuss the potential importance of the AIQ in the selection and coaching processes.
To date, only few United States (US) states have explicit regulations that allow minors to independently give consent for human immunodeficiency virus infection (HIV) prevention treatments. This manuscript will reflect upon key advocacy efforts leading to the revision of the Maryland Minor Consent Law, evaluate current human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) prevention laws for minors in U.S. states, and highlight resources for health advocacy.
Between 2018-2019, public health professionals in Baltimore, Maryland reviewed the Maryland Minor Consent Law and other adolescent consent laws within the U.S. The professionals advocated for a legal review of the gap by the State Senate and the Office of Attorney General.
In May 2019, the public health advocates were successful in their effort for a revision of the Maryland Minor Consent Law to include Treatment for the Prevention of HIV-Consent by minors. Upon their review of all adolescent consent laws within the U.S., they found that only eleven states currently have explicit language indicative of an adolescent’s ability to give consent for pre-exposure prophylaxis (PrEP).
This inquiry can change upstream factors such as laws, regulations, policies and institutional practices.
HIV, Prevention, Pre-exposure prophylaxis, Adolescents, Minor consent law.
The current article contains compilation of significant contributions done by theorists over the years about the phenomenon of perinatal loss. The objective of this paper is to provide information about important emotional and psychological consequences on parents who suffer stillbirth. This article addresses identity issues of the mother, father, and their relationship as a couple. It also provides information on the psychological, emotional, and legal aftermath of healthcare professionals who assist during the process of loss.
Patient-child; Healthcare professionals; Child death.
Prostate cancer is generally multifocal, presenting a lesion with a dominant focus (index lesion) that is characterized by being the lesion with the greatest volume and the biological capacity of invasion to adjacent tissues and distant metastases. With the advent of focal therapy and organ preservation in prostate cancer, it is essential to know the real tumour volume and thus, avoid the persistence of disease after treatments with curative intent. The aim of this study is to correlate the results of the dominant tumour volume obtained from the multiparametric magnetic resonance imaging (MRI) of the prostate and the histopathology.
Material and Methods
A retrospective study was performed which included all radical prostatectomies (RP) with previous MRI. A comparative analysis was performed between the tumour volume obtained from the MRI and the histopathology.
A total of 46 patients were included in the study. The sensibility of the MRI in diagnosing the index lesion was 82.6%, highlighting that all tumours with a Gleason score ≥ 4+3 were diagnosed. The mean tumour volume in the MRI was 14.3 mm and in the histological result was 18.82 mm (p<0.05). The estimation tumour volume concordance was greatest in higher risk (International Society of Urological Pathology (ISUP)).
The MRI underestimates the real tumour volume of the prostate cancer index lesion when compared to the histological result of the surgical piece, being significantly lower in high-risk lesions.
Prostate cancer; MRI; Radical prostatectomy; Index lesion; Tumour volume.
Diabetes mellitus (DM) is a chronic debilitating condition affecting people worldwide and diabetic foot ulcers are also a common problem. The treatment of diabetic ulcers requires a multimodal approach. Adjuvant low-level laser therapy (LLLT) may be useful in lesions with protracted healing course but the evidence is still limited. In this study, we share our experience regarding the use of low-level laser therapy as an adjuvant treatment modality in a patient with diabetic foot ulcer.
Low-level laser therapy; Diabetic ulcer.
Endometrial hyperplasia is defined as the pathological condition caused by hyper plastic changes at the level of the glandular and stromal structures of the endometrium that are part of the lining of the endometrial cavity. Atypical endometrial hyperplasia can cause an essential problem because it is considered a precursor of endometrial cancer. The early diagnosis of precancerous endometrial
lesions and the exclusion of pre-existing endometrial carcinomas are necessary for patients’ optimal management. The following is a case of a 50-year-old Guatemalan patient with a three-day history of vaginal bleeding. The transvaginal ultrasound reports endometrial thickening suggestive of endometrial hyperplasia. The diagnosis was confirmed with histology. The treatment offered was surgery without indicating any medication.
Endometrium; Endometrial hyperplasia; Biopsy; Histological; Echography; World Health Organization (WHO).
Carbon monoxide (CO) is a toxic gas produced as a result of incomplete combustion of organic materials. The source of CO production is very common especially in nations that depend on power generating sets for electricity. Chronic disease is non-communicable and usually takes a longer time to manifest. Examples are kidney failure, diabetes mellitus, hypertension, cancer, and cardiac arrest. These diseases are now very common in society, not sparing the youthful population that was rare ab initio. The major difficulty in the containment of chronic diseases is the inability to establish a definitive causative agent. The definite causative agent is important in public health and management of chronic diseases. Preventive medicine is anchored on establishing the causative agent of a disease. Without knowing the causative agent of a disease, the path to prevention becomes very cumbersome.
The knowledge of the causative agent of a disease is the bedrock of preventive medicine and public health. Several reasons such as lifestyle modification, hereditary, climate change, nutrition or aging have been adduced as the cause of chronic diseases. These reasons are quite weak and not definite. The exact causative agent(s) of chronic diseases is a conundrum that needs a deliberate study and review so as to enhance definite diagnosis, preventive measures and appropriate therapeutic intervention. Measurement of biochemical and haematological parameters are employed in disease diagnosis and management. Alterations of these parameters are used to identify chronic diseases and also form part of an alarm system of a potential breakdown of the normal functioning of the body. The effect of chronic CO intoxication on these parameters could be of importance in establishing causative
agent(s) of diseases that are for long opaque and non-definite. This review was therefore designed to interrogate various narratives, meta-analysis, and researches on this subject. Explicit knowledge of the pattern or presentation of biochemical and haematological parameters arising from chronic CO intoxication could be of great importance in preventive medicine, disease diagnosis and appropriate therapeutic intervention.
Biochemical parameters; Haematological parameters; Chronic diseases; Carbon monoxide; Chronic intoxication.
The 2008 Physical Activity Guidelines recommend that the more than 53 million people living with a physical disability in the United States to participate in regular physical activities consisting of both aerobic and anaerobic components, if possible. Also, if individuals with physical disabilities are unable to meet the recommended physical activity guidelines, they are encouraged to do as much as their physical disability permits. Despite the recommended guidelines, several individuals with physical disabilities do not participate in regular physical activities. Prior research suggests that several societal and structural barriers in sport and exercise environments often negatively affect individuals with physical disabilities. Thus, it is essential for family members, healthcare practitioners, rehabilitation/recreational teams, and community leaders to encourage individuals with physical disabilities to conquer barriers that restrict participation.
Tramadol is a synthetic centrally acting analgesic used worldwide for pain relief, but now abused as a euphoria generating substance. The short- and long-term implications of tramadol intoxication on blood cells and its components are still hazy and controversial.
Our primary aim was to evaluate the alterative pattern of haematological parameters resulting from acute or chronic tramadol intoxication.
The study was made of acute and chronic phases of sixty male rats (Rattusnorvegicus) randomly pair-divided into established groups of six male rats each. The acute stage consisted of a control group of 6 rats administered with normal saline solution, and a treatment group of 6 rats administered with lethal dose of tramadol. The control group for the chronic stage consisted of 6 rats that were administered normal saline solution. Whereas, the tramadol-dependent groups comprised of 3 groups of 6 rats each administered orally with 50 mg/kg, 100 mg/kg, and 200 mg/kg of tramadol for 90 days respectively. Statistical analyses consisted of the one-way analysis of variance (ANOVA), Student’s t-test, and Pearson’s Correlation using the JMP statistical discovery™ software version 14.1. Blood samples were collected after anesthetic sacrifice by cardiac puncture for the analysis of full blood
count and red cell indices using SYSMEX Automated Blood Count machine (SYSMEX KX-21N ANALYZER) and microscopy for blood film reading.
Results of the acute phase of the study showed that the packed cell volume (PCV) in the treatment group (51.00±2.96%) was significantly higher (t=3.99, p=0.002) than control (37.83±1.43%). Similarly, the haemoglobin concentration (Hb) in the treatment group (14.70±0.46 g/dL) was significantly higher (t=5.10, p=0.005) than control (11.55±0.41 g/dL). The mean cell haemoglobin
concentration (MCHC) was significantly lower (t=2.67, p=0.02) in the control group (28.30±0.52 g/dL) than treatment (30.43±0.61 g/dL). However, that of the chronic phase exhibited a progressive increase in platelet count which was proportional to increasing dosage of treatment (t=8.59, p=0.007).
This study has demonstrated that tramadol administration could cause haematological alterations which could be beneficial if administrated optimally and deleterious, if abused. Therefore, indiscriminate and prolonged use of tramadol should be monitored to avert haemotoxicity.
Tramadol; Intoxication rats; Full blood count; Red cell indices.
Retinoblastoma (Rb) is a highly angiogenic tumor, for which anti-vascular endothelial growth factor (VEGF) therapies have shown limited success in clinical setting. Recent investigations demonstrated upregulation of ancillary axis including the platelet-derived growth factor (PDGF) when VEGF is inhibited. This illustrates the need for novel therapeutics. Previous work from our lab showed inhibition of the platelet-derived growth factor receptor-beta (PDGFR-β) by imatinibmesylate (IM), inhibited Rb cells proliferation in vitro. Novel therapies ideally are tumor-specific, leaving normal non-cancerous cells a stroma to perform their homeostatic functions. Rb treatments induce apoptosis of the retinal endothelial cells, causing the release of pro-inflammatory cytokines and chemokines to the microenvironment.
We investigated the role of the PDGFR-β in the tumor microenvironment and how inhibition of this signaling pathway, as a potential targeted therapy, impacts angiogenesis in human retinal microvascular endothelial cells (hRECs), specialized neurons arborizing the retinal microvasculature.
Our results demonstrated that inhibition of the PDGFR-β signaling pathway by IM affects the proliferation of the Rb cells, but not hRECs. PDGFR-β signaling is not required for hRECs angiogenic activity, although it reduces the percentage of VEGF-Aproducing cells.
These results illustrate a lack of functional activity PDGFR-β signaling in hRECs and points to a more tumor-specific therapeutic option. This is of critical importance as success of treatment also depends on the ability of the normal tissues to remain healthy after sensitization and/or killing of the Rb tumor.
Retinoblastoma; Retinal endothelial cells; Ocular oncology; Imatinib mesylate.
Necrotizing fasciitis is a soft tissue bacterial infection that spreads rapidly resulting in the destruction of muscles, skin, and underlying tissue. Necrotizing fasciitis is defined as a fast and progressive inflammatory infection of the fascia leading to secondary necrosis of the subcutaneous tissue moving along the facial plane. Fournier gangrene is a type of necrotizing fasciitis involving the scrotum and perineal area. Patients suffering from acute necrotizing fasciitis require an effective regimen which includes surgical removal of devitalized tissues, systemic antimicrobials and mitigating underlying systemic disease processes. The burden of treating wounds following surgical debridement, on the other hand, can be challenging especially in the third world where resources are scarce resulting in suboptimal wound coverage and function. At primary care level we had the opportunity of using natural honey in 5 patients with non-healing wounds in either the lower limb or scrotum due to acute necrotizing fasciitis. This natural noninvasive approach offers a cost-effective and efficacious alternative to dermatotraction, skin grafting and negative pressure wound therapy. In these patients, the use of natural honey led to the restoration of the appearance and function of the fasciotomy wound especially in patients with co-morbidities or those refusing skin grafting due to cost, religious factors, etc. The authors present the clinical results followed by a discussion on the therapeutic properties of natural honey. This case series demonstrates the efficacy of topical raw honey as a catalyst for speeding the healing process by secondary intention thereby offering a safe and efficacious
alternative for managing various wounds resulting from acute necrotizing fasciitis.
Natural honey; Necrotizing fasciitis; Primary care; Wounds.
Empathy in social work is one of the most important factors that can bring change in the patient, by developing a productive relationship. The purpose of this study is to explore empathy in the practice of social work, as it is used by professional social workers.
Semi-structured interviews were conducted with 12 social workers in public health services in Crete. Responses were recorded, and content analysis was used to analyze the data.
There were differences in the way that social workers perceive the concept of empathy, depending on their prior experiences. It was also found that they are more “sensitive” when patients have a common problem with them. Among the difficulties that prevented them from being empathetic was having “a difficult personal period” that affected their work. This study has also identified the importance of professional training for the development of empathy skills, and the key-role of work experience. Moreover, it highlighted the importance of co-operation between the researchers and the social workers for generating efficacious and valuable information.
This study emphasizes the importance of empathy as a necessary skill in the relationship between social workers and patients, and the need for in-depth scientific research and analyze on this issue in Greece.
Difficulties; Obstacles; Empathy; Social worker; Skill; Patient.
There are global challenges in relation to an increasingly older population, rising numbers of deaths and the resulting need for end-of-life care. It is imperative for Health and Social Care to examine where people die and forward plan.
To establish the place where people have died 2004-2018 and project future place of death care setting by 2040.
Materials and Methods
Population-based trend analysis of place of death for people that died in Northern Ireland (2004-2018 from Northern Ireland Statistics and Research Agency) and projections using linear modelling (2019-2040 projections by Office of National Statistics).
Deaths are projected to increase by 45.9%, from 15,922 in 2018 (of which 36.3% will be aged 85+ years) to 23,231 deaths in 2040 (39.8% aged 85+ years). Between 2004 and 2018, proportions of home and care home (defined as nursing and residential beds) deaths increased (24.5-27% and 16.3-19.4% respectively), while the proportion of hospital deaths declined (51.9-47.6%). If current trends continue, by 2040, deaths within the community (home and care home) will account for between 46.7-55.2% of all deaths. However, if care home capacity is limited at current levels (as of 2018), hospital deaths are projected to account for the largest proportion of deaths by 2040 (51.7%).
Death at an increasing age has implications for end-of-life care provision. This study demonstrates an increasing need for end-of-life care over the next 20-years, particularly within community settings. Projections highlight the need for comprehensive planning to ensure service provision within the community meets the needs of the population.
Trend analysis; Place of death; Community palliative care.
Equitable access to safe abortion is part of the corpus of human rights. Providing women with access to safe abortion means protection and realization of one of their fundamental human rights. However, around the world, even nowadays, women face not only legal obstacles, but as well stigmatization and conviction against fulfillment of the right to abortion. In North Macedonia there a multiple type of barriers and large inequalities related to the accessibility and availability of reproductive healthcare
services. Women with low socio-economic status are mostly affected. The need for contraception has not been met and reproductive healthcare services are unevenly distributed across the country.
Laws; Abortion; Safe; Women’s sexual and reproductive rights; Healthcare services.
Double J (DJ) stenting is a routine procedure in our urological practice to treat ureteral obstruction. We report a rare case where the proximal coil of a DJ stent was found in the second part of duodenum diagnosed on imaging and confirmed by upper gastrointestinal endoscopy, in a patient with chronic right flank pain who underwent emergency right DJ stenting elsewhere. He presented to our institution 3-months later for further management. It is important to be aware of all possible complications before placing DJ stents and be aware that if any such complication arise, they need to be dealt with early. It is important to avoid blind DJ stent insertion especially in acute or inflammatory conditions. One can avoid such situations by stenting under image guidance and preferably with a retrograde pyelogram (RGP) or by deploying a guidewire under direct vision using a ureteroscope. If stent malposition is suspected then early detection and replacement of the malpositioned DJ stent under fluoroscopic guidance is an essential step in management.
Double J stenting; DJ stent malposition; Upper GI endoscopy; DJ stent coil in duodenum; Right contracted kidney; Inflammatory
retroperitoneal mass; Laparoscopic nephrectomy.
Existing research has addressed the importance of community integration (CI) and its benefits of dwelling in a community but has yet to address the methods and efficiency of improving these activities among older people. Thus, it is vital to understand how healthcare workers can integrate the benefits of CI among older people, especially with the use of occupational therapists (OTs). The latter are actively working to improve ageing individuals mobility within the community.
This study aims to identify Malaysian OTs’ perspectives on CI’s and its implication on older people.
Occupational therapist from different states of Malaysia participated in a semi-structured interview, through a virtual medium (Zoom Cloud Meetings). The interview guide encapsulated the theory of critical incident technique (CIT).
Thematic content analysis, over fourteen participants from 13 states of Malaysia, provided insights into CI’s barriers for older people in Malaysia. The findings revealed that multifaceted factors from an individual, organisational and socio-environmental perspective limit older people’s active CI engagement.
South-East Asia hierarchal and collectivist culture play a significant role in influencing all factors of CI. OTs must understand and incorporate appropriate cultural norms during CI practice development for the older population in Malaysia.
Occupational therapist; Critical incident technique; Older people; Community integration; Qualitative study; Societal norms; Cultural norms.
Telogen effluvium (TE) and its acute form (aTE) are two of the commonest occurrences in a trichology clinic, with patients claiming excessive hair shedding. ATE can occur in people of any age and ethnicity and is considered to be a quite common condition in either sex even if women are more likely to have a lowered quality of life and restricted social contacts as compared to men as a result of hair loss. Brittle nail syndrome (BNS) is a common condition affecting up to 20% of the population, especially women over 50 years of age. Nails affected by BNS appear ragged, thin, and dull. The clinical features of BNS include horizontal splits within the nail plate (onychoschizia) and increased longitudinal ridging or splitting (onychorrhexis). In BNS oral supplementation, trace elements and amino acids (especially L-Cystine) have been reported to be useful to ameliorate the nail plate condition.
We hypothesized that a nutritional approach, with nutrients of which the composition is close to the human keratin, could be effective to decrease hair loss during telogen effluvium and to improve brittle nails condition. At this purpose, a clinical study was designed to investigate the efficacy of a natural keratin hydrolysate obtained from a non-human source (feathers) on both aTE and BNS.
The in vivo effects of a natural keratin hydrolysate, Kera-Diet® (KD) upon human hair and nails condition was tested in a randomized, double-blind, parallel-group, benchmark (BE) and placebo (PL) controlled study involving 60 women during 90 days. In all subjects, Anagen/Telogen hair, hair volume and density, pull test, global photography, hair and nails brightness, and nail plate
growth were measured at baseline and after 45 and 90 days of products use. A self-assessment test was carried out at the end of the study.
With the KD treatment group, hair density, percentage of hair in anagen phase, hair and nails brightness, and nails growth were significantly increased compared to PL treatment group. Interestingly, with this same group, the diagnosis of aTE by pull testing was negative from 45 days. The efficacy of KD was equal to or greater than PL treatment group.
In this study, we demonstrated that daily oral administration of 1000 mg during 3 months of a natural extensively keratin hydrolysate, Kera-Diet®, associated to trace elements and specific vitamins was effective to improve both hair and nails condition. Furthermore, it demonstrates the role of nutrients in both aTE and BNS.
Keratin hydrolysate; Oral supplementation; Telogen effluvium; Hair growth; Brittle nail syndrome; Onychoschizia; Clinical study.
Present study was conducted with a theme to develop yoghurt spread from goat milk owing to its therapeutic significance and ameliorate nutritional value and quality of the finished product via supplementation of chia seed oil.
Four treatments (T0, T1, T2 and T3) possessing varying concentrations of chia seed oil (0, 2, 4 and 6%) were formulated and the first was opted as control. Samples were evaluated on 0th, 10th and 20th day for physicochemical (pH, acidity, TSS, total protein, fat), microbiological (total plate count) and sensory acceptance.
Significant changes (increasing or decreasing trends) were perceived in all physicochemical parameters as the storage span progressed however minute differences were observed among different treatments except moisture content which varied significantly among different formulations. Total microbial count also increased with increase in storage days however decreased with increase
in concentration of chia seed oil. Sensorial attributes particularly product acceptability was considerably reduced at the end of storage period.
Generally, addition of chia seed oil at different concentration to yoghurt spread improves the sensory properties and overall acceptability, extends the shelf life and enhances nutrition values. Goat milk is preferable to cow milk owing to essential nutrients it provides to infants and substantial therapeutic significance.
Yoghurt spread; Goat milk; Chia seed oil; Qualitative valorization; Shelf life.
Acute antibody-mediated rejection (aAMR) can negatively impact renal allografts outcomes. To date, there has not been a consistent therapeutic approach to manage aAMR. The aim of the study is to evaluate the tolerance and efficacy of an institutional protocol of methylprednisolone, intravenous gamma globulin (IVIG), rituximab, and bortezomib used to treat aAMR in pediatric renal transplant recipients (pRTRs).
A retrospective chart review was performed on 10 pediatric renal transplant recipients (pRTRs) who were diagnosed with aAMR on a renal biopsy performed between January 2014 and November 2015.
Over the study period, 9.5% of pRTRs had aAMR. Sixty percent of whom had concurrent acute cellular rejection (ACR). Renal allografts survival was 100% during the the first post-aAMR. At the time of diagnosis of aAMR, estimated glomerular filtration rate (eGFR) had decreased by 42% (mean at baseline eGFR=67.2±19.5 mL/min/1.73 m2 vs mean at aAMR eGFR=38.9±14.2 mL/min/1.73 m2; p=0.002). At 1-year post rejection, eGFR had increased by 26% as compared eGFR at the time of rejection (mean eGFR=49.0±13.2 mL/min/1.73 m2; p=0.006). Immuno-dominant donor-specific anti-HLA antibody titers (iDSAs) class I and class II decreased by 69% and 15% at 6-month follow-up visit. No serious opportunistic infections nor malignancy were reported in our subjects.
Our study suggests that our protocol improved kidney function with 100% graft survival at 1-year post aAMR episode. The percentage decline in iDSAs class I titers was more significant than class II. Furthermore, our treatment protocol was well-tolerated with no life threatening complications.
Acute antibody-mediated rejection (aAMR); Intravenous gamma globulin (IVIG); Pediatric renal transplant recipients (pRTRs).
Surrogacy has existed since ancient times. Depending on the way of creating an embryo, two types of surrogacy differ, traditional and gestational. When it comes to monetary compensation, two types of surrogacy exist, altruistic and commercialized. A lot of questions come to light such as: Is the altruistic surrogacy a humane gesture for all contracted parties? What if the mother changes her mind? Do the babies born of surrogacy mothers have rights? In North Macedonia, surrogacy was introduced for
the first time in 2014 in the amended Law on Biomedicine and Assisted Fertilization. It was a novelty having in mind that in the Law of 2008 the surrogacy as a practice was outlawed. The amended law applies the term gestational mother and provides a
liberal stance, but many provisions are unclear.
Laws; Gestational carrier; Commercialization; Altruism; Child rights; Health consequences.
Objective: Technology is rapidly shifting our day-to-day existence, education, social relationships, health care and business. Psychiatric leaders have slowly explored telepsychiatric services – but few have an approach to technology in general–due to
competing clinical, educational and research demands. Technology has typically been added on, rather than integrated, to institutional functions.
Method: This narrative review used a literature search of Medline, PsycNET, PsycINFO, Embase, Cochrane, SpringerLink, Scopus, ABI/Inform, Business Source Complete, and Web of Science, using subject headings and keywords along with a manual search of reference lists of articles published by November 2020. The keywords explored four areas: 1) business; 2) service delivery; 3) system change; and 4) technology. Articles were reviewed by title/abstract, full text review and review of references. They were included if they discussed integration of technology into health care and compared literature from medicine/health, psychiatry/behavioral health, business, technology, leadership and health care administration. The goal was to explore how medicine/psychiatry has integrated technology compared to business, and apply business approaches to health care and training.
Results: From a total of 2,710 potential references, two authors found 327 eligible for full text review and found 69 papers directly relevant to the concepts. Business and medicine/psychiatry have similarities/differences from both historical and contemporary views. Many health care systems and companies lack a strategic plan for technology and focus only on short-term due to administrative demands. Clinical informatics is a rapidly expanding area and would be central to this process. It has started to facilitate patient-centered care as defined by quality, affordable, and timely health care. While in principle information systems use integrative approaches, electronic health records, electronic means of communications with patients and staff, behavioral health indicators and related digital advances are often added to existing systems rather than integrated. Effective businesses use integrative approaches to share domain knowledge and streamline prac