Παρασκευή 1 Ιανουαρίου 2021

The tubarial glands



The tubarial glands: Discovered but not defined – A narrative review
Tarun Kumar Suvvari, Nithya Arigapudi

Journal of Radiation and Cancer Research 2020 11(4):140-141

A pair of salivary glands, named as tubarial glands, was found between the nasal cavity and throat, i.e., at the nasopharynx's lateral walls, overlaying the torus tubarius by the Netherlands Cancer Institute while working on radiation toxicity among prostate cancer patients. The tubarial glands were identified using prostate-specific membrane antigen imaging using positron emission tomography coupled with computed tomography, which is used to detect the spread of prostate cancer. The anatomy, physiology, oncological study of the glands, and data's interpretation and limitations from the research to date have been discussed.

#
Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,
Telephone consultation 11855 int 1193,

Nervous System Diseases

Comparison of factor structure and psychometric properties of original and abbreviated version of the Penn State Worry Questionnaire in a nonclinical sample: a cross-sectional psychometric study
Alireza Rashtbari, Hossein Malekizadeh, Omid Saed

Asia Pacific Journal of Clinical Trials: Nervous System Diseases 2020 5(4):43-50

Background and objectives: Worry as a main symptom of generalized anxiety disorder is a chain of repetitive and uncontrollable thoughts about possible negative events in the future. The Penn State Worry Questionnaire is one of the most widely used measures for assessing pathological worry. The purpose of the present study was to investigate the psychometric properties of the abbreviated version of the Penn State Worry Questionnaire-Abbreviated (PSWQ-A) and to compare it with the original version of the Penn State Worry Questionnaire (PSWQ) in a nonclinical sample. Participants and methods: The present study is a cross-sectional psychometric study. The statistical population of this study consisted of all students studying at Zanjan University of Medical Sciences (n = 3500) from January to October 2018. A sample of 350 people was selected for the study. Research measures were the PSWQ-A, PSWQ, and the Generalized Anxiety Disorder 7-item (GAD-7) Scale. The present study was carried out after approval of Social Determinants of Health Research Center of Zanjan University of Medical Science with the project code of A-12-924-5 on October 7, 2017. The project was also approved by the Ethics Committee of Zanjan University of Medical Sciences on October 17, 2017 and the approval ID was IR.ZUMS.REC.1396.187. Results: Exploratory factor analysis, scree plot, and parallel analysis supported the single factor structure PSWQ-A. The total variance explained by the single-factor model of PSWQ-A was higher (53.1% versus 49.1%). Generally, fit indices for the PSWQ-A was better fitted than the PSWQ. Both measures had acceptable convergent validity (r=0.52 for both questionnaires) and satisfactory internal consistency (α=0.87 for both questionnaires). Conclusion: PSWQ-A has better psychometric properties compared to PSWQ, and it can be used for faster and more accurate assessment of worry in psychological studies and therapeutic settings.


Key enzymes of glutamate metabolisms in the brain of neonatal and adult rats exposed to monosodium glutamate
Uche Stephen Akataobi

Asia Pacific Journal of Clinical Trials: Nervous System Diseases 2020 5(4):51-57

Background and objectives: Despite the effective role of monosodium glutamate as a food additive, there are claims indicating that monosodium glutamate consumption increases the level of glutamate an excitatory neurotransmitter which can be toxic to the brain in accumulated level. The present study attempted to understand the differential effect of monosodium glutamate on key enzymes of glutamate metabolisms in rat brain exposed either as neonate or adult to monosodium glutamate. Methods: The rat neonates were divided into six groups with seven animals per group and exposed to different concentrations of monosodium glutamate as neonates only (normal saline or monosodium glutamate 4 mg/g), neonate plus adults (monosodium glutamate 5 or 10 mg/g) and adult only (monosodium glutamate 5 or 10 mg/g). Key enzymes of glutamate metabolisms were measured in whole brain homogenates. All experiments were approved by the Faculty of Basic Medical Sciences University of Calabar and ethics committee-04/11/2018. Results: Except neonate plus adult 5 mg/g group, glutamate dehydrogenase and glutamate synthetase activities were significantly higher in administered groups than in the control group (P < 0.05). There was no significant difference in glutamate synthetase activity among monosodium glutamate administered groups (P > 0.05). The glutamate carboxylase activity was significantly higher in all monosodium glutamate administered groups than in the control group (P < 0.05). The brain alanine aminotransferase and aspartate aminotransferase activities of rats in each monosodium glutamate administered group increased in a dose-dependent manner (P < 0.05). Conclusion: Exposure to monosodium glutamate can increase the activities of key enzymes of glutamate metabolism in the brain of neonate and adult rats similarly, which is not determined by age difference.


Effect of Ayurveda gut therapy protocol in managing dysbiosis of children with autism: study protocol for a randomized controlled trial
Dinesh Karayil Subramanian, Anita Patel, Madathaniyil Joseph George, Swapna Chitra Sugunanandagopan, Santhi Krishna, Sujitha Variyattukunnu Kelu, Jayakrishnan Kalluvirath, Archana Madhavi

Asia Pacific Journal of Clinical Trials: Nervous System Diseases 2020 5(4):58-64

Background and objectives: Emerging evidences indicate an invariable relationship between gut dysbiosis and neurobehavioral symptoms of autism spectrum disorder. In India, Ayurveda is widely accepted among the complementary and alternative medicine. This study aimed to assess the efficacy of an Ayurveda gut therapy protocol in autism spectrum disorder. Subjects and methods: In this randomized controlled trial, 60 children with autism spectrum disorder admitted to Vaidyaratnam P S Varier Ayurveda College, India will be randomly assigned to intervention and control groups. The intervention group will undergo Ayurveda gut therapy protocol for 30 days and interdisciplinary interventions for 2 months, whereas the control group will undergo only interdisciplinary interventions for 2 months. A final assessment will be done on the 60 th day. Patient recruitment began in July 2018. The primary and secondary outcome measure will be completed in January 2021 and the study will be completed in September 2022. The study was approved by the Institutional Ethical Committee of Vaidyaratnam P S Varier Ayurveda College, India (Proceedings No: IEC/CI/24/17) on May 4, 2017. Protocol version: 1.0. Outcome measures: The expected primary outcome is to assess the quality and quantity of the gut microbes through 16s rRNA sequencing. The secondary outcome expected is the changes in the neurobehavioral symptoms assessed through the Childhood Autism Rating Scale and also changes in the gastrointestinal symptoms assessed through Ayurveda Gut Health Assessment Questionnaire. Discussion: The current protocol discusses the relationship between Autism and gut dysbiosis and its management through Ayurveda, and provides evidence for the rationality of using Ayurveda gut therapy as an alternative therapy for autism spectrum disorder in clinical practice. Trial registration: The study was registered with Clinical Trial Registry of India (registration No. CTRI/2018/05/014017, registered on May 21, 2018).



#
Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,
Telephone consultation 11855 int 1193,

Academic Medicine

Humanizing the Morbidity and Mortality Conference
Morbidity and mortality conferences (MMCs) are a long-held legacy institution in academic medicine that enable medical providers and hospital administrators to learn from systemic and individual errors, thereby leading to improved medical care. Originally this forum had 1 major role—education. The MMC evolved and a second key role was added: quality improvement. In the wake of the 2020 COVID-19 pandemic, a second evolution—one that will humanize the MMC—is required. The pandemic emphasizes the need to use MMCs not only as a place to discuss errors but also as a place for medical providers to reflect on lives lost. The authors' review of the literature regarding MMCs indicates that most studies focus on enabling MMCs to become a forum for quality improvement, while none have emphasized the need to humanize MMCs to decrease medical provider burnout and improve patient satisfaction. Permitting clinicians to be human on the job requires restructuring the MMC to provide a space for reflection and, ultimately, defining a new purpose and charge for the MMC. The authors have 3 main recommendations. First, principles of humanism such as compassion, empathy, and respect, in particular, should be incorporated into traditional MMCs. Second, shorter gatherings devoted to giving clinicians the opportunity to focus on their humanity could be arranged. Third, an MMC focused entirely on the human aspects of medical care could be periodically arranged to provide an outlet for storytelling, artistic expression, and reflection. Humanizing the MMC—a core symposium in clinical medicine worldwide—could be the first step in revitalizing the spirit at the heart of medicine, one dedicated to health and healing. This spirit, which has been eroding as the field of medicine becomes increasingly corporate in structure and mission, is as essential during peaceful times in health care as during a pandemic. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimers: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. Correspondence should be addressed to Haider J. Warraich, 4B-132, 1400 VFW Parkway, Boston VA Healthcare System, Boston, MA 02132; telephone: (617) 323-7700; email: hwarraich@partners.org; Twitter: @haiderwarraich. Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a "work of the United States Government" for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government. © 2020 by the Association of American Medical Colleges

Perceptual Facilitators for and Barriers to Career Progression: A Qualitative Study With Female Early Stage Investigators in Health Sciences
Purpose: Despite efforts to increase the representation of women in the national scientific workforce, results still lag. While women's representation in health-related sciences has increased substantially, women remain underrepresented in senior leadership roles. This study was conducted to elucidate influences at the individual, interpersonal, organizational, and societal levels that present as barriers to and facilitators for advancement in research careers for women, with the goal of promoting and retaining a more diverse leadership. Method: The authors conducted individual, 1-hour, in-depth, semistructured interviews with 15 female early stage investigators pursuing careers in health sciences research at a large minority-serving institution in Florida in 2018. Interview guides were designed by using a social ecological framework in order to understand the influence of multilevel systems. Employing a qualitative approach, drawing from a phenomenological orientation, 2 researchers independently coded transcripts and synthesized codes into broad themes. Results: Barriers and facilitators were reported at all ecological levels explored. Illustrative quotations reflect the unequal distribution of familial responsibilities that compete with career advancement, family members' lack of understanding of the demands of a research career, the importance of female mentors, perceived differences in the roles and expectations of female and male faculty at institutions, and normative upheld values that influence early career progression. Conclusions: Achieving pervasive and sustained changes that move toward gender equity in research requires solutions that address multilevel, explicit and implicit influences on women's advancement in science. Suggestions include shifting familial and institutional norms, creating support systems for women with female mentors, and enforcing consistent policies regarding the roles and expectations of faculty. Findings shed light on the influence of gender on career progression by providing context for the experiences of women and underscore the importance of addressing pervasive societal and structural systems that maintain inequities hindering women's progress in the scientific workforce. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/B57. Acknowledgments: The authors would like to thank the participants who took part in the study, without whom this work would not be possible. Funding/Support: This research was supported in part by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under award NIMHD U54MD012393, Florida International University Research Center in Minority Institutions. Other disclosures: None reported. Ethical approval: This study was approved by the institutional review board for the study site located in South Florida, as recorded in application IRB-18-0268, reference number 106877. Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Previous presentations: This work was presented at the RCMI (Research Centers in Minority Institutions) Translational Science Conference, Capacity Building and Investigator Development track; December 2019; Bethesda, Maryland. Correspondence should be addressed to Sofia B. Fernandez, 11200 SW 8th Street, AHC4-328, Miami, FL 33199; telephone: (305) 348-0365; fax: (305) 348-5801; email: sofernan@fiu.edu. © 2020 by the Association of American Medical Colleges

Hispanic Identity and Its Inclusion in the Race Discrimination Discourse in the United States
As protests against racism occur all over the United States and medical institutions face calls to incorporate antiracism and health equity curricula into professional training and patient care, the antiracism discourse has largely occurred through a Black/African American and White lens. Hispanics, an umbrella category created by the U.S. government to include all people of Spanish-speaking descent, are the largest minority group in the country. Hispanics are considered an ethnic rather than a racial group, although some Hispanics self-identify their race in terms of their ethnicity and/or country of origin while other Hispanics self-identify with any of the 5 racial categories used by the U.S. government (White, Black or African American, American Indian or Alaska Native, Asian, or Native Hawaiian or Other Pacific Islander). Expanding the antiracism discourse in medicine to include Hispanic perspectives and the diversity of histories and health outcomes among Hispanic groups is crucial to addressing inequities and disparities in health and medical training. A lack of inclusion of Hispanics has contributed to a growing shortage of Hispanic physicians and medical school faculty in the United States as well as discrimination against Hispanic physicians, trainees, and patients. To reverse this negative trend and advance a health care equity and antiracist agenda, the authors offer steps that medical schools, academic medical centers, and medical accreditation and licensing bodies must take to increase the representation of Hispanics and foster their engagement in this evolving antiracism discourse. Acknowledgments: The authors wish to acknowledge the work of the Latino Medical Student Association, the National Hispanic Medical Association, and all organizations representing Hispanics in medicine, both past and present. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Cristina R. Fernández, Department of Pediatrics, Columbia University Irving Medical Center, 630 West 168th Street, PH-17 Room 201-I, New York, NY 10032; telephone: (212) 342-1758; email: crf2101@cumc.columbia.edu; Twitter: @DrCFernandez. © 2020 by the Association of American Medical Colleges

Everyday Heroism: Maintaining Organizational Cultures of Wellness and Inclusive Excellence Amid Simultaneous Pandemics
Health care professionals and the institutions in which they work are being stretched to their limits amidst the current COVID-19 pandemic. At the same time, a second longstanding pandemic has been brought to the fore: the entrenched system of racial injustice and oppression. The first pandemic is new and to date substantial resources have been allocated to urgently addressing its mitigation; the second has a long history with inconsistent attention and resources but has recently been spotlighted more intensely than at any time in the nation's recent past. The authors of this article contend that these 2 simultaneous pandemics have brought forth the need for institutions in the United States to make a renewed commitment to respect, wellness, diversity, and inclusion. While investment and leadership in these domains have always been essential, these have largely been viewed as a "nice-to-have" option. The events of much of 2020 (most notably) have illustrated that committing to and investing in policies, programs, centers, and leadership to drive change in these domains are essential and a "need-to-have" measure. The authors outline the necessity of investing in the promotion of cultures of inclusive excellence at both individual and organizational levels to coordinate a united response to the simultaneous pandemics. It is in the interests of health care systems to consider the wellness of the workforce to overcome the longer term economic, systemic, and social trauma that will likely occur for years to come at both the individual and institutional levels. Maintaining or augmenting investment is necessary despite the economic challenges the nation faces. Now is the time to cultivate resilience and wellness through a renewed commitment to cultures of respect, diversity, and inclusion. This commitment is urgently needed to support and sustain the health care workforce and maintain outstanding health care systems for future generations. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Magali Fassiotto, PhD, Stanford University School of Medicine, Stanford, CA, 94305; telephone: (650) 723-6078; email: magali.fassiotto@stanford.edu; twitter: @StanfordMedOFDD. © 2020 by the Association of American Medical Colleges

Novel Prescriptions From Medical Schools for Physician–Scientist Training and Engagement in the Twenty-First Century
Physicians engaged in biomedical research are well positioned to directly focus the discovery process on human biology. However, the relative proportion of investigators engaged in both caring for patients and conducting research is decreasing. To address the dwindling numbers of physician–scientists nationally, the Burroughs Wellcome Fund (BWF) created the Physician-Scientist Institutional Awards Program by dedicating 25 million dollars to new initiatives at 10 degree-granting, accredited medical schools in North America, awarded on the basis of institutions' proposals. The perceived barriers to physician–scientist training, program initiatives, and commitment to training a diverse group of future researchers were articulated in each application. In all, the BWF review committee considered 136 distinct proposals from 83 medical schools, representing 54% of all accredited medical schools in North America. Barriers identified by more than one-third of the applicant institutions included the absence of both mentors and role models, student indebtedness, institutional cultures that valued clinical care delivery above the discovery process, limited prior relevant research experience, and structural barriers that limited scheduling flexibility during training. Awards were granted to institutions with programs designed to be sustainable and overcome critical, prospectively identified barriers to training and retention of physician–scientists. Potential solutions from the 10 funded programs were focused on different stages of the training experience. Though a determination about the relative success of each of the initiatives will take many years, careful consideration of the barriers identified and more general application of specific program component may be beneficial in increasing the numbers of physicians actively involved in biomedical research. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to John E. Burris, Burroughs Wellcome Fund, 21 T.W. Alexander Drive, P.O. Box 13901, Research Triangle Park, NC 27709-3901; email: jburris@bwfund.org. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2020 by the Association of American Medical Colleges

Recognizing Cross-Institutional Fiscal and Administrative Barriers and Facilitators to Conducting Community-Engaged Clinical and Translational Research
Purpose: This qualitative study examined fiscal and administrative (i.e., pre- and post-award grants process) barriers and facilitators to community-engaged research among stakeholders across 4 Clinical and Translational Science Awards (CTSA) institutions. Method: A purposive sample of 24 key informants from 3 stakeholder groups—community partners, academic researchers, and research administrators—from the CTSA institutions at the University of North Carolina at Chapel Hill, Medical University of South Carolina, Vanderbilt University Medical Center, and Yale University participated. Semistructured interviews were conducted in March–July 2018, including questions about perceived challenges and best practices in fiscal and administrative processes in community-engaged research. Transcribed interviews were independently reviewed and analyzed using the Rapid Assessment Process to facilitate key theme and quote identification. Results: Community partners were predominantly Black, academic researchers and research administrators were predominantly White, and women made up two-thirds of the overall sample. Five key themes were identified: level of partnership equity, partnership collaboration and communication, institutional policies and procedures, level of familiarity with varying fiscal and administrative processes, and financial management expectations. No stakeholders reported best practices for the institutional policies and procedures theme. Cross-cutting challenges included communication gaps between stakeholder groups, lack of or limits in supporting community partners' fiscal capacity, and lack of collective awareness of each stakeholder group's processes, procedures, and needs. Cross-cutting best practices centered on shared decision-making and early and timely communication between all stakeholder groups in both pre- and post-award processes. Conclusions: Findings highlight the importance of equitable processes, triangulated communication, transparency, and recognizing and respecting different financial management cultures within community-engaged research. This work can be a springboard used by CTSA institutions to build on available resources that facilitate co-learning and discussions between community partners, academic researchers, and research administrators on fiscal readiness and administrative processes for improved community-engaged research partnerships. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/B55. Acknowledgments: Adina Black and Elisa D. Quarles served as reviewers in the Rapid Assessment Process. Adina Black provided administrative support in developing this manuscript. Jennifer Teixeira, director of research administration in the Office of Sponsored Research at University of North Carolina at Chapel Hill, contributed to the conceptualization of this project. The authors thank the stakeholders—community partners, academic researchers, and research administrators—for participating in this study. Funding/Support: This work was supported, in part, by the Clinical and Translational Science Awards Program, funded by the National Center for Advancing Translational Sciences of the National Institutes of Health: grants #UL1TR002489 (University of North Carolina at Chapel Hill), #UL1TR001450 (Medical University of South Carolina), #UL1TR002243 (Vanderbilt University Medical Center), and #UL1TR001863 (Yale University). Other disclosures: None reported. Ethical approval: The University of North Carolina at Chapel Hill Institutional Review Board approved this study on September 8, 2017 (IRB#15-0849). Disclaimers: The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Correspondence should be addressed to Lori Carter-Edwards, University of North Carolina at Chapel Hill, Campus Box 7064, 160 N. Medical Dr., Chapel Hill, NC 27599; telephone: (919) 966-5305; email: lori_carter-edwards@unc.edu; Twitter: @NCTraCS. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2020 by the Association of American Medical Colleges

Effect of Continuing Professional Development on Health Professionals' Performance and Patient Outcomes: A Scoping Review of Knowledge Syntheses
Purpose: Continuing professional development (CPD) programs, which aim to enhance health professionals' practice and improve patient outcomes, are offered to practitioners across the spectrum of health professions through both formal and informal learning activities. Various knowledge syntheses (or reviews) have attempted to summarize the CPD literature; however, these have primarily focused on continuing medical education or formal learning activities. Through this scoping review, the authors seek to answer the question, What is the current landscape of knowledge syntheses focused on the impact of CPD on health professionals' performance defined as behavior change and/or patient outcomes? Method: In September 2019, the authors searched PubMed, Embase, CINAHL, Scopus, ERIC, and PsycINFO for knowledge syntheses published between 2008 and 2019 that focused on independently practicing health professionals and reported outcomes at Kirkpatrick's levels 3 and/or 4. Result: Of the 7,157 citations retrieved from databases, 63 satisfied the inclusion criteria. Of these 63 syntheses, 38 (60%) included multicomponent approaches, and 27 (43%) incorporated eLearning interventions – either stand-alone or in combination with other interventions. While a majority of syntheses (n = 42 [67%]) reported outcomes affecting health care practitioners' behavior change and/or patient outcomes, most of the findings reported at Kirkpatrick level 4 were not statistically significant. Ten of the syntheses (16%) mentioned the cost of interventions though this was not their primary focus. Conclusions: Across health professions CPD is an umbrella term incorporating formal and informal approaches in a multi-component approach. eLearning is increasing in popularity but remains an emerging technology. Several of the knowledge syntheses highlighted concerns regarding both the financial and human costs of CPD offerings, and such costs are being increasingly addressed in the CPD literature. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/B56. Acknowledgments: The authors would like to thank Rhonda Allard, a medical librarian at Uniformed Services University of the Health Sciences, for helping design, refine, and conduct the searches for this study. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimer: The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense or the Henry M. Jackson Foundation for Military Medicine. Correspondence should be addressed to Anita Samuel, Uniformed Services University of the Health Sciences, Department of Medicine, Graduate Programs in Health Professions Education, 4301 Jones Bridge Road, Bethesda, MD 20814; telephone: (301) 295-9539; email: anita.samuel.ctr@usuhs.edu. Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a "work of the United States Government" for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government. © 2020 by the Association of American Medical Colleges

Personalized Graduate Medical Education and the Global Surgeon: Training for Resource-Limited Settings
Problem: The World Health Organization and the World Bank have identified improvement in access to surgical care as an urgent global health challenge and a cost-effective investment in public health. However, trainees in standard U.S. general surgery programs do not have adequate exposure to the procedures, technical skills, and foundational knowledge essential for providing surgical care in resource-limited settings. Approach: The Michael E. DeBakey Department of Surgery at Baylor College of Medicine (BCM) created a 7-year global surgery track within its general surgery residency in 2014. Individualized rotations equip residents with the necessary skills, knowledge, and experience to operate in regions with low surgeon density and develop sustainable surgical infrastructures. BCM provides a formal, integrated global surgery curriculum—including 2 years dedicated to global surgery—with surgical specialty rotations in domestic and international settings. Residents tailor their individual experience to the needs of their future clinical practice, region of interest, and surgical specialty. Outcomes: There have been 4 major outcomes of the BCM global surgery track: (1) increased exposure for trainees to a broad range of surgeries critical in resource-limited settings, (2) meaningful international partnerships, (3) contributions to global surgery scholarship, and (4) establishment of sustainable global surgery activities. Next Steps: To better facilitate access to safe, timely, and affordable surgical care worldwide, global surgeons should pursue expertise in topics not currently included in U.S. general surgical curricula, such as setting-specific technical skills, capacity building, and organizational collaboration. Future evaluations of the BCM global surgery track will assess the effect of individualized education on trainees' professional identities, clinical practices, academic pursuits, global surgery leadership preparedness, and comfort with technical skills not encompassed in general surgery programs. Increasing availability of quality global surgery training programs would provide a critical next step towards contributing to the delivery of safe surgical care worldwide. Acknowledgements: The authors wish to thank Miriam King, MEd, Scott LeMaire, MD, Chad Wilson, MD, MPH, C. Anne Morrison, MD, MPH, Walter Johnson, MD, MPH, MBA, Neema Kaseje, MD, MPH, Nader Masserweh, MD, MPH, Josephine Koller, BBA, Sydney Webster, MEd, Jaye Chambers, Allyson Bremer, Woods McCormack, MA, Bip Nandi, MBBChir, Heather Vasser, MD, Kathryn Gunter, MD, Michael Coburn, MD, Michael Belfort, MBBCH, DA (SA), MD, PhD, Jeffrey Wilkinson, MD, Rachel Pope, MD, MPH, Kelli Barbour, MD, Candy Wilburn, Etan Weinstock, MD, Peter Hotez, MD, PhD, John Dawson, MD, Christopher Perkins, MD, MS, Adam Gibson, JD, Taylor Napier, MA, Hisashi Nikaidoh, MD, Lynn Nikaidoh, Craig Brown, Sue Smith, JD, and John Collier, MDiv, MA. Funding/Support: Funding and support for the creation of the global surgery residency track were received from the Baylor College of Medicine Michael E. DeBakey Department of Surgery, Hitoshi Nikaidoh Memorial Endowment, George A. Robinson IV Foundation, Craig and Galen T. Brown Foundation, CHRISTUS Foundation for HealthCare, Caring Friends in Deed, and the Bridget L. Harrison, MD International Education Support Fund. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Rachel W. Davis, Baylor College of Medicine, 1 Baylor Plaza, MS390, Houston, TX, 77030; telephone: (713) 798-6078; email: rachelwdavis@bcm.edu; Twitter: @RachelWDavis. © 2020 by the Association of American Medical Colleges

Discharge Communication: A Multi-Institutional Survey of Internal Medicine Residents' Education and Practices
Purpose: To characterize residents' practices around hospital discharge communication and their exposure to transitions-of-care instruction in graduate medical education (GME). Method: In spring 2019, internal medicine residents at 7 academic medical centers completed a cross-sectional survey reporting the types of transitions-of-care instruction they experienced during their GME training and the frequency with which they performed 6 key discharge communication practices. The authors calculated a mean discharge communication score for each resident and, using multiple logistic regression, they analyzed the relationship between exposure to types of educational experiences and the discharge communication practices that residents reported to perform frequently (> 60% of time). The authors also used content analysis to explore factors that motivated residents to change their discharge practices. Results: The response rate was 63.5% (613/966). Resident discharge communication practices varied. Notably, only 17.0% (n = 104) reported routinely asking patients to "teach-back" or explain their understanding of the discharge plans. The odds of frequently performing key discharge communication practices were greater if residents received instruction based on observation of and feedback regarding their communication with patients at discharge (adjusted odds ratio [OR] 1.73; 95% confidence interval [CI], 1.07-2.81), or if they received explicit on-rounds teaching (adjusted OR 1.46; 95% CI, 1.04-2.230). In open-ended comments, residents reported that experiencing adverse patient events at some point in the post-discharge continuum was a major impetus for practice change. Conclusions: This study exposes gaps in hospital discharge communication with patients, highlights the benefits of workplace-based instruction on discharge communication skills, and reveals the influence of adverse events as a source of hidden curricula. The results suggest that developing faculty to incorporate transitions-of-care instruction in their rounds teaching and integrating experiences across the post-discharge continuum into residents' education may foster physicians-in-training who are champions of effective transitions of care within the fragmented healthcare system. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/B54. Acknowledgements: The authors would like to thank Shreya Singhal and Megan Sutter, PhD, for statistical assistance, as well as Amy Ou, MD, Masha Slavin, MD, Bilal Alqam, MD, Marina Baskharoun, MD, Nick Gowen, MD, Paul Williams, MD, and Derek Hupp, MD, for help distributing the survey. Funding/Support: Dr. Shreya P. Trivedi's time was supported by Health Resources and Services Administration-T32 grant (T32HP22238). Other disclosures: None reported. Ethical approval: Ethical approval was received from each participating institution. Previous presentations: The findings of this study were presented as a virtual oral presentation for the Lipkin Finalist Award for the Society of General Internal Medicine On-Demand 2020 National Conference. Data: The data for this study were not collected from outside sources. Correspondences should be addressed to Shreya Trivedi, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, Massachusetts 02215; telephone: (215) 527-9238; email: strived1@bidmc.harvard.edu; Twitter: @ShreyaTrivediMD. © 2020 by the Association of American Medical Colleges

Sin-Eaters
No abstract available


#
Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,
Telephone consultation 11855 int 1193,

Haematology

Prognostic impact of Annexin A1 expression in acute myeloid leukemia
Mohmoud Gaber, Ali M Kasem, Mohamed Azzazi, Mohamed Tarif, Emad A Yusuf

The Egyptian Journal of Haematology 2020 45(2):57-67

Objective The aim was to assess expression of Annexin A1 (ANXA1) on malignant myeloid blast cells and its correlation with clinical outcome, overall survival (OS), and other prognostic factors among adult Egyptian patients with acute myeloid leukemia (AML). Patients and methods A total of 60 patients with de novo AML were treated and followed up in Ain Shams University Hospitals, Hematology Unit and compared with 20 age-matched and sex-matched normal healthy controls. Expression of ANXA1 was detected by flow cytometry in bone marrow samples. Results Patients with AML had significant higher mean ANXA1 expression than mean ANXA1 expression in control at D0. The mean ANXA1 level in the favorable cytogenetics group was significantly higher than the mean ANXA1 level in the unfavorable cytogenetics group. ANXA1 was positive in 76.7% patients with AML and negative in 23.3% patients with AML. There was a significant difference between ANXA1-positive group and ANXA1-negative group of patients with AML regarding different outcomes. In ANXA1-positive group, 52.2% of patients with AML achieved complete remission (CR), whereas in ANXA1-negative group, 14.3% of patients with AML achieved CR. Highest mean ANXA1 expression was in the group of patients who had CR. High ANXA1 expression was associated with longer OS. Conclusion ANXA1 is significantly expressed in Egyptian patients with de novo AML, and its expression associated with favorable prognostic effect on clinical outcome and longer OS.


Assessment of serum interleukin-15 in adult acute leukemia patients (Egyptian sample)
Mohamed M Moussa, Mahmoud Sheeba, Emad Abdel Mohsen, Mohamed Elshazly, Nour E Hussein

The Egyptian Journal of Haematology 2020 45(2):68-76

Background Interleukin 15 (IL-15), proinflammatory cytokine, regulates immune system functions and controls hematopoietic cell differentiation. It promotes leukemia development through enhancing survival, proliferation, and differentiation of leukemic precursors. Aim The aim was to assess the expression of IL-15 level in adult Egyptian acute leukemia patients, its correlation with disease-free survival, overall survival and relapse rate, and its possible correlation with other prognostic parameters. Patients and methods Serum IL-15 was measured using ELISA in 30 newly diagnosed acute lymphoblastic leukemia (ALL) patients, 30 newly diagnosed acute myeloid leukemia (AML) patients, and 30 healthy controls recruited from Ain Shams University Hospital from 2017 to 2018. Results In ALL patients IL-15 was higher in patients compared with the control. IL-15 was higher in patients with non-high-risk cytogenetics compared with those with high-risk cytogenetics. Patients with high IL-15 who achieved first complete response (CR) were less than those with low/average IL-15. Patients with high IL-15 who achieved minimal residual disease (MRD) negativity were less than those with low/average IL-15. Patients with high IL-15 had shorter survival compared with those with low/average IL-15 level. Optimal cutoff value for IL-15 in predicting patient survival in ALL patients was 200&#8201;ng/l. In AML patients: IL-15 was higher in patients compared with the control. IL-15 was higher in patients with high-risk features compared with those without. Patients with high IL-15 achieved first CR less than those with average IL-15. Patients with high IL-15 achieved MRD negativity less than those with average IL-15. Patients with high IL-15 had shorter survival compared with those with low/average IL-15. Optimal cutoff value for IL-15 in predicting patient survival in AML patients was 190&#8201;ng/l. IL-15 has negative correlation with death date in AML patients. Conclusion IL-15 is a useful poor prognostic marker in newly diagnosed acute leukemia patients&#8217; also it can be used as a predictor for CR, MRD, and survival.


Lymphocyte DNA damage in children with iron-deficiency anemia: a case–control study
Aneseya P Varghese, Smriti Sinha, Seema P Sindgikar, Rathika D Shenoy, Vijaya Shenoy

The Egyptian Journal of Haematology 2020 45(2):77-80

Context Iron-deficiency anemia (IDA) is a widespread yet one of the most neglected micronutrient deficiency disorder worldwide. Aims The objective was to evaluate lymphocyte DNA damage in children with anemia. Materials and methods This was a prospective case&#8211;control study. A total of 80 infants and children aged six months to twelve years were included. Fifty had IDA, whereas 30 were controls. DNA damage scoring using alkaline comet assay was done in all children. Percentage and mean and/or SEM were calculated. Comparison between cases and controls was done using Student&#8217;s t test. Analysis of variance test was used to compare the groups within the cases and controls. Pearson correlation coefficient was performed to relate the hemoglobin levels with the DNA damage. Statistical software was used for analysis. Results DNA damage scoring was significant in all the parameters in the iron-deficiency group with respect to the tail length and percentages of DNA in tail and olive moment, with a P value of 0.006, 0.002, and 0.038, respectively. A statistically significant negative correlation was found between hemoglobin levels and percentage of DNA in tail (r&#61;&#8722;0.280; P&#61;0.012) as well as olive moment (r&#61;&#8722;0.240; P&#61;0.032) Conclusion IDA was associated significantly with lymphocyte DNA damage. A significant negative correlation between hemoglobin levels and percentage of DNA and olive moment was also elucidated. The authors conclude that early intervention is needed in even mild cases of IDA.


Prognostic value of platelet glycoprotein Ibα (Kozak) gene polymorphism in patients with coronary heart disease
Mohamed Sabry El-Ghonemy, Solafa El Sharawy, Mahmoud M AbdoYouseif, Shaimaa El-Ashwah, Menna T-Allah Fayez, Ahmed EL-Sebaie

The Egyptian Journal of Haematology 2020 45(2):81-86

Background Coronary heart disease (CHD) is one of the leading causes of death worldwide for both men and women. It is caused by the disproportion between myocardial oxygen demand and its supply. Platelets play an important role in thrombosis and hemostasis by forming a plug at the exposed subendothelium preventing blood loss; if this process is uncontrolled it results in thrombotic events causing life-threatening disease such as myocardial infarction (MI) or ischemic stroke. Glycoprotein (GP) Ib-IX-V is a platelet membrane receptor complex containing four polypeptides, GPIb&#945;, GPIbB, GPIX, and GPV, which plays a key role in mediating platelet activity and thrombosis. This study aimed to evaluate the role of platelet GPIb&#945; (Kozak) gene polymorphism as a risk factor of CHD. Patients and methods This study was conducted on 120 newly diagnosed patients of CHD admitted to the Internal Medicine Hospital [46 patients with unstable angina (UA) and 74 patients with MI]. Thirty apparently healthy individuals served as a control group. The EDTA blood samples collected from patients and the control group were subjected to DNA extraction, followed by PCR amplification for the Kozak gene. Results This study showed that by taking rs2243093 TT as the reference genotype and T as the reference allele. TC, CC, TC+CC genotypes, and C allele showed a lower frequency in cases when compared with the control group, with protective effect against CHD susceptibility (P&#60;0.05). On the other hand, no association was found in GP1b&#945; genotypes and alleles between UA and MI subgroups (P&#62;0.05). Conclusion Individuals carrying the C allele of (rs2243093) had protective effect against CHD including UA, MI. The rs2243093 had no association with the risk of MI in those having UA. Wild genotype (TT) was associated with higher creatine kinase-MB, while genotypes containing the risk allele (C) had lower creatine kinase-MB in CHD patients.


Sociodemographic and clinical determinants of folate deficiency among sickle cell anemia patients in Kano, North Western Nigeria
Ibrahim Abdulqadir, Aisha A Galadanci, Mujtaba I Mashi, Sagir A Gumel, Aisha K Gwarzo

The Egyptian Journal of Haematology 2020 45(2):87-91

Context Folate deficiency is common among sickle cell anemia (SCA) patients and could be influenced by factors such as clinical and social conditions. Sociodemographic and clinical determinants of folate deficiency have not been previously investigated among SCA patients in this environment. Aims The aim was to determine the sociodemographic and clinical factors associated with folate deficiency in SCA patients accessing care at Aminu Kano Teaching Hospital, Kano. Settings and design This was a cross-sectional study involving 110 SCA participants at steady state. Patients and methods Sociodemographic and clinical data of the participants were collated, while their folate status was determined using Roche Elecsys 2010. Statistical analysis Data were analyzed with SPSS version 21.0 and level of significance was set at P less than or equal to 0.05. Results The mean age of the participants was 14.9&#177;7.1 years and the majority of them were men (58, 52.7%), students (96, 87.3%), and jaundiced (66, 60.0%). Age, sex, occupation of the participants, and mother&#8217;s level of education were significantly associated with folate deficiency (P&#60;0.05). Female gender [odds ratio (95% confidence interval) for red blood cells 2.6 (1.2&#8211;5.7) and serum 2.8 (1.3&#8211;6.1)] and mothers with less than secondary education [odds ratio (95% confidence interval) for red blood cells 5.3 (1.0&#8211;27.6) and serum 4.2 (1.0&#8211;18.1)] were independent predictors of folate deficiency. Conclusion Sociodemographic and clinical characteristics are important determinants of folate deficiency in SCA. We therefore recommend periodic assessment of folate status as part of the standard care to SCA patients to prevent complications of folate deficiency.


A potential immunological diagnostic marker for acute myeloid leukemia: the expression of the immune checkpoint B and T lymphocyte attenuator
Sara M Radwan, Nooran S Elleboudy, Nermeen A Nabih, Amal A El-kholy, Amany M Kamal

The Egyptian Journal of Haematology 2020 45(2):92-96

Introduction Provided the physiologic tumor suppressive role a healthy immune system has, diagnosis of cancer is sometimes also regarded as a diagnosis of an immune dysfunction. Immunoediting refers to the change of immune system response from tumor protection to tumor promotion, favoring the growth of poorly immunogenic clones that have the ability to evade the immune response. Among the mechanisms by which the tumor cells bypass the immune system is immune checkpoints. Which are immune inhibitory pathways responsible for self-tolerance and limiting self-tissue damage by controlling the magnitude and duration of the immune reaction. Objective Studying the expression of the novel immune checkpoint BTLA in patients with AML and evaluate its clinicopathological and diagnostic significance. Patients and methods We investigated the expression of BTLA gene in 60 AML cases and 15 healthy controls using RT-PCR. Results The current study revealed that significant up regulation of BTLA mRNA expression in AML patients as in comparison with the control group (P&#61;0.024). Discussion These results provide a basis for the perception that BTLA upregulation is involved in inhibition of antitumor immunity and that high BTLA expression level can be made use of as a diagnostic marker in patients with AML.


Longitudinal assessment of the impact of tuberculosis infection and treatment on monocyte–lymphocyte ratio, neutrophil–lymphocyte ratio, and other white blood cell parameters
Chizoba O Okeke, Grace I Amilo, Martin O Ifeanyichukwu, Ejeatuluchukwu O Obi

The Egyptian Journal of Haematology 2020 45(2):97-104

Context Tuberculosis (TB) is a major infectious disease usually marked by alterations in white blood cell (WBC) parameters which are known to play a major role in the normal body response to infections. Aim The aim was to assess the impact of TB infection and treatment on monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), and other WBC parameters in TB individuals before and in the course of therapy. Settings and design This was a longitudinal follow-up study that included 60 TB-infected individuals, age 18 and 80 years. The TB individuals were recruited at Mile-Four Hospital Abakaliki before initiation of therapy and followed up at 2 months and 6 months into treatment. Materials and methods TB diagnosis was done using both Ziehl&#8211;Neelsen acid fast bacilli test and GeneXpert Mycobacterium tuberculosis/rifampicin assay. Whole blood collected in dipotassium ethylenediamine tetraacetic acid was used for the measurement of total white blood cell count and differential white cell count (neutrophil, lymphocyte, monocyte, eosinophil) and packed cell volume. The MLR and NLR were calculated. Statistical Package for the Social Sciences (SPSS), version 22 was used for statistical analysis. Results The findings showed that total white cell count, neutrophil count, lymphocyte count, eosinophil count, and monocyte count (&#215;109/l) were all significantly decreased after 2-month treatment compared with the pretreatment values (P&#60;0.05) and all except monocyte was significantly increased after 6-month treatment (P&#60;0.05). There was a significant decrease in NLR and MLR after 2 months of treatment that was maintained after 6 months of treatment. Moreover, the packed cell volume (l/l) increased significantly after 2 months of treatment and decreased significantly after 6 months of treatment. Conclusion TB is associated with significant changes in NLR, MLR, and other WBC parameters which might be possible markers to explore as a prognostic index in TB disease.


β-catenin mutations in acute myeloid leukemia
Buket A Gunes, Tulin Ozkan, Aynur K Gurel, Yalda Hekmatshoar, Meral Beksac, Asuman Sunguroglu

The Egyptian Journal of Haematology 2020 45(2):105-110

Background Acute myeloid leukemia (AML) is a hematopoietic stem cell disorder characterized by uncontrolled proliferation and impaired differentiation of normal hematopoietic stem or progenitor cells. Various pathways like RAF/MEK/ERK, PI3K/AKT, receptor tyrosine kinases, members of RAS family, and Wnt/&#946;-catenin are disrupted in AML. Stabilization of &#946;-catenin, the key point of activated Wnt/&#946;-catenin pathway, has been shown in AML in various studies. One of the mechanisms that may lead to the &#946;-catenin stabilization is the mutations in exon 3 at its N-terminal domain, where &#946;-catenin is phosphorylated particularly during the degradation process, and these mutations have been investigated in chronic myeloid leukemia and many other cancer types. Aim &#946;-Catenin gene exon 3 mutations were analyzed in this study with the aim of determining the relationship between mutations and molecular biology of AML. Patients and methods In this study, we examined &#946;-catenin gene mutations in AML cell line U937 and 31 untreated patients with AML by using the DNA sequence analysis for the first time in a Turkish population. Results No &#946;-catenin gene exon 3 mutations were detected in patients with AML and the cell line. Conclusion &#946;-catenin mutations have been detected in various types of cancer; however, the authors did not find any mutation in this gene, which may be responsible for the activation of Wnt signaling in AML. Further research is required to understand the mechanisms apart from mutations that may induce &#946;-catenin stabilization in AML.


Hyperhomocysteinemia is associated with deep vein thrombosis in Nigerian patients
Sunday P Ogundeji, Taiwo R Kotila, Foluke A Fasola

The Egyptian Journal of Haematology 2020 45(2):111-114

Background Hyperhomocysteinemia is a modifiable risk factor associated with deep venous thrombosis (DVT). Low serum concentrations of vitamin B12 and folate are modifiable causes of hyperhomocysteinemia. This study was carried out to determine the prevalence of hyperhomocysteinemia in Nigerian patients with DVT and also to assess the association of homocysteine with vitamin B12 and folate. Patients and methods A case&#8211;control study was carried out in which serum homocysteine, vitamin B12, and folate levels were measured in 45 Doppler ultrasound confirmed cases of DVT and 43 controls. Hyperhomocysteinemia was defined by serum levels more than 15.0&#8201;&#956;mol/l, low serum folate less than 3&#8201;&#956;g/l, and low serum vitamin B12 less than 160&#8201;ng/l. Results The prevalence of hyperhomocysteinemia in DVT patients was 20 (44.4%) compared with four (9.35%) in the control (P&#60;0.001). The mean serum folate and vitamin B12 levels of DVT patients were 8.7&#177;4.8 and 725&#177;475, while that of the controls were 9.3&#177;3.8&#8201;&#956;g/l and 821&#177;393&#8201;ng/l (P&#61;0.51 and 0.36), respectively. There was no correlation between hyperhomocysteinemia and low vitamin B12 and folate levels. Conclusion Hyperhomocysteinemia may be a risk factor for DVT in the Nigerian population but may not be responsible for thrombosis in all cases. There was however no significant correlation between serum level of homocysteine and serum levels of vitamin B12 and folate in DVT patients. Therefore, larger sized sample studies should be carried out to investigate the relationship between hyperhomocysteinemia and related vitamins as well as genetic causes of hyperhomocysteinemia in DVT patients in our environment.


Burkitt lymphoma presenting with nasopharyngeal mass and generalized lymphadenopathy in a HIV-positive patient
Manasi Mundada, Faiq Ahmed, Rachna Khera, Sudha Murthy, Pavan Kumar Boyella

The Egyptian Journal of Haematology 2020 45(2):115-117

Burkitt lymphoma is an aggressive B-cell neoplasm arising from the germinal center B cells. Clinically, it exists in three forms: endemic, sporadic, and immunodeficiency associated. Immunodeficiency-associated Burkitt lymphoma is usually extranodal and occurs with a CD4 count more than 200&#8201;&#956;l. We report a retrospective study of a 47-year-old male patient, seropositive for HIV infection, presenting with nasopharyngeal mass and generalized lymphadenopathy. His CD4 count was 192 cells/&#956;l, and lactate dehydrogenase was high. Diagnosis was established by biopsy, immunohistochemistry, and fluorescence in-situ hybridization. He was treated with chemotherapy. The disease progressed to involve central nervous system despite treatment. He received palliative radiotherapy and was stable at 11-month follow-up. This report highlights the uncommon clinical presentation, heavy disease burden, and progression of the disease in a HIV seropositive patient.



#
Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,
Telephone consultation 11855 int 1193,

Environmental Disease

Prevalence of open defecation among households with toilets and associated factors in rural areas of district Sonepat in Haryana
Babita Rani, Anshu Yadav, Sanjay Kumar Jha, Anita Punia, Sanjeet Singh

Environmental Disease 2020 5(4):87-92

Context: Constructing latrines and getting people to use them is one of the most effective means of improving public health and saving lives. However, building toilets alone cannot eliminate open defecation. Aims: The aim was to estimate the prevalence of open defecation and factors associated with open defecation in rural areas of a district of Haryana. Settings and Design: This community-based cross-sectional study was carried out in a rural field practice area attached to the department of community medicine of a rural medical college. Subjects and Methods: The study was carried out from July to October 2019. The data were collected from 368 randomly selected households on a pretested semi-structured proforma. Ethical approval was obtained from the institutional ethics committee. Statistical Analysis Used: The data were analyzed using the software R, version 3.6.2. Chi-square, Fisher&#39;s exact test, crude odds ratio, adjusted odds ratio with 95&#37; confidence interval, and P value were calculated. Results: The prevalence of open defecation was 30.97&#37; despite having a household toilet. Among the study participants practicing open defecation, the prevalence of open defecation was significantly higher among scheduled caste (64.9&#37;), illiterates (42.7&#37;), laborers (56.6&#37;), and low family income (41.5&#37;). The participants who have constructed latrine recently, i.e., &#60;1 year before (87&#37;), latrine constructed by government expenses (76.9&#37;), and rarely cleaning of the latrine (76.5&#37;) also contributed significantly. Multivariate logistic regression analysis showed that four of these predictor variables, caste, occupation of the head of the family, years since latrine constructed, and latrine cleaning remained significant predictors of open field defecation. Conclusions: Open defecation is common among latrines owners. This behavior is associated with various several structural and sociocultural factors. The present sanitation campaign should consider shifting from toilet construction to toilet use.


Swine barn dust stimulates CCL9 expression in mouse monocytes through protein kinase C-delta activation
David Schneberger, Jane M Devasure, Kristina L Bailey, Debra J Romberger, Todd A Wyatt

Environmental Disease 2020 5(4):93-99

Objective: Exposure to organic barn dusts has been shown to cause numerous lung problems to chronically exposed animal barn workers. Bacterial components in these dusts trigger innate immunity in the lungs. In characterizing these responses, we examined the expression of a lesser examined chemokine believed to be a lower avidity signal for neutrophil migration, CCL9, and how its expression is controlled by dust exposure in a monocyte/macrophage cell line. Materials and Methods: CCL9 expression was assessed in the RAW267.4 macrophage cell line exposed to organic hog barn dust extracts (HDEs) or components of this dust such as lipopolysaccharide (LPS) and peptidoglycan. CCL9 expression was assessed as well as response of CXCL1 (keratinocyte-derived chemokine [KC]). Protein kinase C (PKC)-&#945;, &#950;, and &#948; were inhibited to assess CCL9 expression. Results: HDE was able to induce significant increase of CCL9 expression in RAW264.7 cells. The ability of HDE to induce CCL9 relied upon LPS present in HDE samples. Addition of CCL9 to RAW264.7 cells stimulated with organic dust reduced KC expression. Further, CCL9 expression was particularly sensitive to PKC-&#950; inhibition by chemical or siRNA. Conclusion: CCL9 is an inducible chemokine present in mouse monocytes exposed to HDE. HDE-induced production of CCL9 appears primarily mediated by LPS in HDE samples. This induction appears to require PKC signaling, with emphasis on PKC-&#950; expression.


High frequency ultrasonography of the facial nerve: Another effective method to observe the course of idiopathic facial nerve paralysis
Jing Zhu, Xiaohua Li, Yang Han, Yu Cao, Longfei Guan, Xiaokun Geng

Environmental Disease 2020 5(4):100-106

Objective: This study was designed to investigate and compare both ultrasonographic and electrophysiological methods of examination of the facial nerve in idiopathic facial paralysis (IFP). Materials and Methods: Patients with IFP diagnosed between January 2018 and June 2019 (n &#61; 178) underwent ultrasonographic and electrophysiological examinations of the facial nerve, within the 1st week of symptoms and every 1&#8211;3 following weeks until asymptomatic, with comparisons between the affected and unaffected sides. Results: There were significant differences in the ultrasonographic diameter and the electrophysiological results obtained from the facial nerve between the affected and unaffected sides. Ninety-one patients completed follow-up and underwent re-examination of the facial nerve by ultrasonography and/or electromyography. The difference between the affected and unaffected sides in terms of the ultrasonographic diameter of the facial nerve gradually decreased with the course of the disease. The ultrasonographic diameter of the facial nerve of the affected side was greater by 0.3 mm than that of the unaffected side for more than 3 weeks, indicative of a poor prognosis, which was consistent with the electrophysiological results. Conclusions: The combination of ultrasonographic and electrophysiological examinations of the facial nerve serves to better guide clinical treatment and assess the prognosis of IFP.


Magnitude of fluorosis and various interventions to reduce fluorosis in Gujarat, India
Sangita V Patel, Kedar Gautambhai Mehta, Prakash V Kotecha

Environmental Disease 2020 5(4):107-111

Background: Gujarat is one of the endemic states for the prevalence of fluorosis due to high fluoride levels in water of many villages in the state. Aim and Objectives: To determine the prevalence of dental fluorosis and skeletal fluorosis in Vadodara district, Gujarat, India, and to document various interventions conducted by Government to reduce the prevalence of fluorosis in Gujarat. Materials and Methods: A cross sectional survey was carried out in 11 villages (6 with high fluoride level and 5 with normal fluoride level) by house to house visits. Various interventions like capacity building of faculties, diagnostic, treatment and counseling for fluorosis and alternate water supply facilities were provided. Results: The prevalence of dental fluorosis and skeletal fluorosis was 59.31&#37; and 18.65&#37; in high fluoride areas, while it was 39.21&#37; and 12.54&#37; in normal fluoride areas, respectively. After estimation of this problem, and other research studies carried in Gujarat, the Government of Gujarat provided a fluorine meter to measure the fluoride level in water and urine in all government medical colleges of the state. Capacity building of faculties from various departments was done regarding the epidemiology, diagnosis, treatment, and counseling of fluorosis patients. Early diagnosis and treatment were provided to all fluorosis patients visiting tertiary care hospitals. Alternate drinking water supply was also provided by the government. Conclusion: Both dental and skeletal fluorosis was high in Gujarat and field level diagnostic facilities are inadequate. A coordinated training program helped to identify the problem and suggest remedial measures. An integrated and comprehensive approach is required to reduce the problem of fluorosis in Gujarat.


Diesel exhaust particles induced oxidative stress, autophagy, and apoptosis in human umbilical vein endothelial cells
Yang Guo, Longfei Guan, Yu Ji, Hangil Lee, Wenjing Wei, Changya Peng, Xiaokun Geng, Yuchuan Ding

Environmental Disease 2020 5(4):112-119

Background: Air pollution is one of the greatest public health concerns worldwide. In order to understand its mechanism of harm, we investigated the effects of diesel exhaust particles (DEPs), one of the major constituents of ambient air pollutants, on reactive cell viability, oxygen stress, autophagy, and apoptosis. Materials and Methods: In in vitro human umbilical vein endothelial cell (HUVEC) model, cells were exposed to freshly dispersed DEP preparations at 0, 12.5, 25, 50, 100, or 200 &#181;g/mL for 24 h or at 50 &#181;g/mL DEP for 1, 3, 6, 12, or 24 h. Cell survival and oxidative stress were determined by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay, activity of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (NOX), and generation of reactive oxygen species (ROS). Protein expressions of autophagy (Beclin-1, p62, and light chain 3 [LC3]-II) and apoptosis (Bcl2 and Bax) were assayed by Western blotting. Results: DEP induced a significant dose-dependent and temporal decrease in cell viability and increase in ROS generation and NOX activity, in association with decreased or increased protein levels of p62 or Beclin-1, as well as conversion of the LC3 in a dose-dependent manner. DEP increased pro-apoptotic protein Bax and decreased anti-apoptotic protein Bcl2. Conclusions: These results demonstrated that DEP exposure induced cytotoxicity, oxidative stress, autophagy, and apoptosis in HUVECs. Novel insight into the mechanisms of cardiovascular diseases caused by air pollution may be provided through these findings.


Envisaging political commitment and financial investment to accomplish elimination of all forms of viral hepatitis by 2030
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava

Environmental Disease 2020 5(4):120-121




#
Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,
Telephone consultation 11855 int 1193,

Transplantation

The impact of comorbidities on clinical course and outcome, in kidney transplant recipients with COVID-19: A systematic review and analysis
Amit Bansal, Anant Kumar, Richa Mittal Bansal, Ruchir Maheshwari, Samit Chaturvedi

Indian Journal of Transplantation 2020 14(4):275-282

Background: The literature on the impact of comorbidities on the severity and outcome of COVID-19 in kidney transplant patients is limited. We aimed to review the same. Methods: We conducted this review as per Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. PUBMED, Embase, Scopus, and Science Direct were searched for studies, available online till May 31, 2020. Studies reporting comorbidities, clinical course, and outcome of each kidney transplant patient with COVID-19 were included. Studies on any other organ transplant, recommendations, or review articles were excluded. The impact of comorbidities on severity and outcome was assessed. The study appraisal was done using Joanna Briggs Institute Critical Appraisal Checklist. Continuous variables were compared using Mann&#8211;Whitney U-test. Categorical variables were compared using Fisher&#39;s exact test. A univariate and multivariate logistic regression for predictors of severity and outcome, was done. P &#60; 0.05 was considered statistically significant. The study protocol was registered with PROSPERO (CRD42020190114). Results: We analyzed 19 studies (56 patients) out of the 355 identified. The most common comorbidity was hypertension (83.92&#37;). Nearly 30.35&#37; of the patients had severe clinical course. The mortality rate was 19.64&#37;. Advanced age was statistically significantly associated with severe course (P &#61; 0.0173) and death (P &#61; 0.0005). Men were more likely to have nonsevere course (P &#60; 0.0001). No comorbidity had any impact on the severity or outcome. Patients with severe disease had higher odds of dying (P &#61; 0.002). Conclusions: Comorbidities were not found to have any significant impact, hence the contribution of immunosuppression toward the severity of COVID-19 needs to be studied. Ours is the first review to assess the impact of comorbidities in kidney transplant patients with COVID-19 but limited by the number of patients.


Urinary tract infections in kidney transplantation: An emerging crisis of drug resistance
Praveen Kumar Etta

Indian Journal of Transplantation 2020 14(4):283-287



Clinical profile of SARS-CoV-2 infection in kidney transplant patients - A single centre observational study
Maithrayie Kumaresan, Madushri Babu, Rajeevalochana Parthasarathy, Milly Matthew, Chandramouleeswari Kathir, Anusha Rohit, Georgi Abraham

Indian Journal of Transplantation 2020 14(4):288-292

Background: In India, 8.27 million documented cases of COVID 19 and a total of 123K deaths have been reported till October 2020. We were able to estimate the clinical consequences of SARS CoV 2 in 16 patients over a period of 5 months. The disease prevalence and mortality rate observed in transplant recipients were found to be higher than in the general population. Aims and Objectives: A retrospective analysis of COVID 19 infections in kidney transplant recipients and the outcome. Materials and Methods: A single centre observational study of all patients who have undergone kidney transplant between March 2001 and December 2019 and documented evidence of SARS CoV 2 infection between March 2020 and October 2020. From a large cohort of 720 kidney transplant recipients, 16 recipients who developed COVID 19 infection were studied. They were all on maintenance immunosuppression in varying doses. None of the patients in this cohort had any recent episodes of cellular rejection requiring heightened immunosuppression. The vintage of the transplant varied from 9 to 192 months. Results: Acute kidney injury was identified in two patients. Eight patients were home quarantined and eight patients were hospitalized. All patients had a reduction in immunosuppression during the covid 19 infection dosage based on the severity of the disease. Out of the hospitalized patients, three died, two of whom had stable functioning grafts and the cause of death was identified as acute lung injury 1 patient had post covid ACR which was treated with Injection. Methyl Prednisolone. Conclusions: In our study, 2.22&#37; developed COVID-19 disease and the mortality rate was 18.75&#37; among those who developed COVID-19. The disease prevalence and mortality rate observed in transplant recipients were found to be higher than in the general population. Obesity, diabetes mellitus, and systemic hypertension were identified as independent risk factors.


Comparison of the CMV antigenemia and CMV-DNA QPCR results in haematopoetic stem cells transplanted recipients - A retrospective observational study
Habib Ksouri, Yosra Chebbi, Anis Raddaoui, Wafa Achour

Indian Journal of Transplantation 2020 14(4):293-297

Objectives: Diagnosis of active cytomegalovirus (CMV) infection in hematopoietic stem cell (HSC)-transplanted patients is essential because of the serious complications it causes, especially CMV disease. Such diagnosis allows the initiation of a preemptive antiviral therapy, which avoids the development of such disease. In this retrospective study made as a part of routine work for transplanted patients, we compared two diagnosis testing for CMV-active infection such as pp65 CMV antigenemia and a quantitative real-time polymerase chain reaction (QPCR). Our purpose was to assess the contribution of these tools to the diagnosis and monitoring of active CMV infections. Materials and Methods: Five hundred and fifty-eight and 156 samples belonging to 24 HSC transplanted patients were, respectively, tested by antigenemia and QPCR. Results: For the 156 samples analyzed by both testing, a number of positive samples by a QPCR were higher than that by antigenemia (44.8&#37; vs. 13&#37;), with a statistically significant difference (P &#60; 0.0001). A statistically significant correlation between viral loads of these two testing was also found (rs &#61; 0.765). In median, QPCR becomes positive 14 days before antigenemia (P &#60; 0.0001) and its positivity lasts for 91 days, whereas antigenemia positivity lasts only for 56 days (P &#60; 0.001). No statistically significant difference was found between the results of these two testing in CMV disease cases. Conclusions: QPCR is a rapid, standardized assay, which permits a precocious detection of CMV DNA. Kinetic of DNA evolution is a reliable diagnostic tool and more effective than antigenemia-based assays in monitoring CMV infection.


A prospective study of correlation of blood levels of tacrolimus to graft function and adverse effect of tacrolimus in postrenal transplant patients
Krishna Asuri, Virinder Kumar Bansal, Sujoy Chatterjee, Omprakash Prajapati, Mahesh Chandra Misra

Indian Journal of Transplantation 2020 14(4):298-305

Introduction: There are limited data on the symptoms of immune-suppressive therapy after transplant on Indian patients and how tacrolimus blood level correlates with graft function and its adverse effects. This study was planned to study these factors. Materials and Methods: The study was conducted as a prospective longitudinal study. Adult patients who underwent the live renal transplant and matched the inclusion criteria from March 2018 to April 2019 were enrolled for the study. Trends of all the parameters were analyzed and their correlation was done with corresponding tacrolimus blood levels. Blood for tacrolimus level was collected at d1, 5, 15, 30, 90, and 180, and values of serum creatinine, diabetes status, hypertensive status, lipid profile, infection occurrence, and liver function tests were recorded at the same time. The subjective symptom occurrence was also recorded by Modified Transplant Symptom Occurrence and Symptom Distress Scale questionnaire at 3 months. Results: The mean age of the study population was 33.7 &#177; 10.1 years. The incidence of infection was highest at 48&#37; in the 1&#8211;3 month period. The incidence of posttransplant diabetes mellitus (PTDM) was 13.7&#37;. Patients requiring antihypertensive decreased from 93.1&#37; immediate posttransplant to 51.5&#37; after 6 months of transplant. There was an increase in posttransplant triglyceride levels, total cholesterol, and low-density lipoprotein level with only high-density lipoprotein showing a protective trend. Liver functions did not show any derangements during the study period. There was no significant correlation between any of the adverse effects and tacrolimus blood levels. Excessive appetite was the most commonly experienced symptoms whereas tremor was the most distressing one. There was a statistically significant increase in symptoms experienced in patients whose tacrolimus blood level was above the normal level for that period. Conclusion: Our study showed no significant correlation between blood levels of tacrolimus and graft function and also with hypertension, dyslipidemia, PTDM, and incidence of posttransplant infections. The incidence of adverse effects was significantly higher in patients who had tacrolimus blood levels higher than recommended.


The role of povidone-iodine in prevention of lymphorrhea after kidney transplant surgery - A prospective, pilot study
Dilip Kumar Pal, Pinaki Roy, Amvrin Chatterjee, Debarshi Jana, Debasish Mandal

Indian Journal of Transplantation 2020 14(4):306-312

Objective: Lymphatic complications (lymphorrhea or lymphocele) are one of the most common and frustrating complications of renal transplantation. It was well documented in literatures that excessive lymphatic leak in the early postoperative period leads to lymphorrhea, which may transform into lymphocele. Povidone-iodine has been used as a sclerosant in lymphocele management for the past 30 years. In this study, our aim is to establish the role of povidone-iodine to prevent lymphorrhea after kidney transplant surgery. Materials and Methods: A total of 106 (live donor transplant patient &#61; 63 and deceased donor transplant patient 43) patients had undergone renal transplantation from May 2019 to May 2020. Those patients were randomized into three groups &#8211; Group A (n &#61; 35): where 1&#37; povidone-iodine was used, Group B (n &#61; 35): where 5&#37; povidone-iodine was used, and Group C (n &#61; 36): control group, where povidone-iodine was not used. Fifty milliliters of 1&#37; or 5&#37; povidone-iodine was used to wash the bed and kept for 5 min in contact with the bed and again 1&#37; (Group A) or 5&#37; (Group B) povidone-iodine wash was given after completion of ureteroneocystostomy and was kept for 5 min. Results: On postoperative day 6, there is a statistically significant decrease in drain output in the 5&#37; and 1&#37; povidone-iodine groups in comparison with the control group, but no statistically significant difference exists between 5&#37; versus 1&#37; povidone-iodine group. Conclusion: Intraoperative instillation povidone-iodine is a cheap, safe, and very effective procedure to prevent lymphorrhea following renal transplant surgeries.


Pediatric kidney transplantation: Long-term outcome of living versus deceased donor program from a single center- A retrospective observational study
Kinnari B Vala, Himanshu V Patel, Vivek B Kute, Divyesh P Engineer, Pankaj R Shah, Dinesh N Gera, Pranjal R Modi, Jamal S Rizvi, Bina Butala, Shruti Mehta, Vineet M Mishra

Indian Journal of Transplantation 2020 14(4):313-320

Background: Kidney transplantation (KT) is widely accepted as most successful treatment option for patients with end-stage kidney disease (ESKD) for better survival and quality of life for both children as well as adults. Data scarcity on long term outcome of living donor (LD) versus deceased donor (DD) pediatric KT in developing countries prompted us to review our experience. Aims and Objectives: To determine(1) long term graft, (2)patient survival outcome and (3) rejection episodes in LD versus DD pediatric KT in developing country. Patients and Methods: This was a retrospective observational analysis of 151 LD and 37 DD pediatric renal transplants (age &#8804;18 years) performed at a tertiary care center between 1998 and 2011. This study was under taken to evaluate long term patient and graft survival, rejection episodes and other complications. Demographic details for all patients was retrieved. Kaplan-Meier curves were used for survival analysis. Results: Over a mean follow-up of 4.2 &#177; 3.61 years, one-, five- and ten- year death-censored graft survival in LDKT was 87.4&#37;, 72.1&#37;, 72.1&#37; and patient survival was 92.5&#37;, 80.9&#37;, 75.1&#37; respectively; 19.8&#37; (n &#61; 30) patients had biopsy proven acute rejection (BPAR) and 17.8&#37; (n &#61; 27) patients died, mainly due to infections (n &#61; 12). In DDKT, over mean follow-up of 3.93 &#177; 3.5 years, one-, five- and ten-year death-censored graft survival was 90.4&#37;, 86.4&#37; ,73.3&#37; and patient survival was 83.4&#37;, 67.9&#37;, 67.9 &#37;, respectively; 21.6&#37; (n &#61; 8) patients had BPAR and 27&#37; (n &#61;10) patients died, mainly owing to infections (n &#61; 6). Conclusion: LDKT or DDKT in children has acceptable graft function with patient/graft survival over long-term follow-up, encouraging to develop sustained deceased donor program in developing countries. However, infections are major cause of morbidity and mortality.


Establishing a deceased donor transplantation program and its impact in a public sector hospital in India – A single centre experience from India
JIPMER Deceased Donor Transplantation Committee (JDDTC)

Indian Journal of Transplantation 2020 14(4):321-332

Introduction: Organ transplantation is growing in India but is mostly dependent on living donors. Deceased donor organ procurement has grown in certain parts of the country in the past decade. However, brain death certification and organ procurement predominantly happen in private health-care sector, with less contribution from public sector hospitals. Expanding the infrastructure for deceased donor transplantation program, especially in the public sector hospitals, is likely the most important step toward improving deceased donor organ donation rates in a country like India. Methods: Here, we describe our experience with setting up a deceased donor program in a public sector hospital and its outcomes. Results: We harvested organs and tissues from 42 deceased donors between December 2013 and March 2020. The deceased donor program has helped in establishing a multi-organ transplantation program at our center, including liver and hand transplantation, in addition to kidney and corneal transplantation. Conclusion: Gathering a committed team of direct stakeholders with domain expertise, creating an organizational system, and establishing clear standard operating procedures (SOPs) are critical for success, in addition to physical infrastructure.


Renal transplantation in polycythemia vera:- A rare case report from India
Prashant Bharat Malviya, Sanjay Maitra

Indian Journal of Transplantation 2020 14(4):333-334

Polycythemia vera (PV) is a rare myeloproliferative neoplasm usually associated with JAK2 mutation. Manifestations include blood circulation disorder, hypertension and cerebral infarction. Renal disease is quite uncommon in PV and only few cases have been reported in the literature. In majority of these cases it was considered that PVinduced glomerular hyperperfusion and hyperfiltration as a cause of CKD. PV with ESRD and undergoing successful renal transplantation is much rarer. We here report one such patient of PV who had Budd Chiari syndrome, underwent hepatic vein stenting. He developed CKD which progressed to ESRD and underwent renal transplantation. To the best of our knowledge it is first case report from India.


Heart transplant recipient with features of COVID-19 infection: First case report from India
Dhruva Sharma, Sunil Dixit, Anil Sharma

Indian Journal of Transplantation 2020 14(4):335-337

A 16-year-old boy has been reported 3 months postcardiac transplantation with chief complaints of nausea, vomiting, pain in abdomen, and fever. The patient had remarkably increased serum lactate dehydrogenase levels, triglycerides, serum amylase, and serum lipase. The B-type natriuretic peptide level more than 35,000 ng/mL and troponin T was increased (0.57 &#956;g/ml). Last known concentration of tacrolimus was 9 ng/ml. Supraventricular tachycardia was remarkable on electrocardiogram. His computed tomographic findings revealed bilateral pneumothorax with bilateral pleural effusion with an opacity seen in the right upper lobe. Bedside echo revealed dilated right atrium and right ventricle with left ventricular ejection fraction of 60&#37;. He was kept on immunosuppression of mycophenolate mofetil 360 mg (2 tablets twice a day) and tacrolimus (2.5 mg twice a day). His reverse transcriptase-polymerase chain reaction throat swabs of the patient were sent for testing 2019-nCoV and were found to be negative. The patient could not be revived in spite of all medical management.



#
Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,
Telephone consultation 11855 int 1193,