Search results for: Population-base cohort study

Authors: Shraddha Acharya, Sharad Kumar Sharma, Ratna Bhattarai, Bhagwan Maharjan, Deepak Dahal, Serpahine Kaminsa

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Background: Drug-resistant (DR) tuberculosis (TB) continues to be a threat in Nepal, with an estimated 2800 new cases every year. The treatment of DR-TB with second line TB drugs is complex and takes longer time with comparatively lower treatment success rate than drug-susceptible TB. Delay in treatment initiation for DR-TB patients might further result in unfavorable treatment outcomes and increased transmission. This study thus aims to determine median time taken to initiate second-line treatment among Rifampicin Resistant (RR) diagnosed TB patients and to assess the proportion of treatment delays among various type of DR-TB cases. Method: A retrospective cohort study was done using national routine electronic data (DRTB and TB Laboratory Patient Tracking System-DHIS2) on drug resistant tuberculosis patients between January 2020 and December 2022. The time taken for treatment initiation was computed as– days from first diagnosis as RR TB through Xpert MTB/Rif test to enrollment on second-line treatment. The treatment delay (>7 days after diagnosis) was calculated. Results: Among total RR TB cases (N=954) diagnosed via Xpert nationwide, 61.4% were enrolled under shorter-treatment regimen (STR), 33.0% under longer treatment regimen (LTR), 5.1% for Pre-extensively drug resistant TB (Pre-XDR) and 0.4% for Extensively drug resistant TB (XDR) treatment. Among these cases, it was found that the median time from diagnosis to treatment initiation was 6 days (IQR:2-15.8). The median time was 5 days (IQR:2.0-13.3) among STR, 6 days (IQR:3.0-15.0) among LTR, 30 days (IQR:5.5-66.8) among Pre-XDR and 4 days (IQR:2.5-9.0) among XDR TB cases. The overall treatment delay (>7 days after diagnosis) was observed in 42.4% of the patients, among which, cases enrolled under Pre-XDR contributed substantially to treatment delay (72.0%), followed by LTR (43.6%), STR (39.1%) and XDR (33.3%). Conclusion: Timely diagnosis and prompt treatment initiation remain fundamental focus of the National TB program. The findings of the study, however suggest gaps in timeliness of treatment initiation for the drug-resistant TB patients, which could bring adverse treatment outcomes. Moreover, there is an alarming delay in second line treatment initiation for the Pre-XDR TB patients. Therefore, this study generates evidence to identify existing gaps in treatment initiation and highlights need for formulating specific policies and intervention in creating effective linkage between the RR TB diagnosis and enrollment on second line TB treatment with intensified efforts from health providers for follow-ups and expansion of more decentralized, adequate, and accessible diagnostic and treatment services for DR-TB, especially Pre-XDR TB cases, due to the observed long treatment delays.

Keywords: drug-resistant, tuberculosis, treatment initiation, Nepal, treatment delay

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Authors: Arman Kishan, Mark Haft, Steve Li, Duc Nguyen, Dawn Laporte

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Objective: Patients with Type 2 diabetes (T2DM) often face higher postoperative complication rates. Limited data exist on outcomes in T2DM patients undergoing carpal tunnel release (CTR). This study aims to compare complication rates between endoscopic CTR (ECTR) and open CTR (OCTR) in patients with T2DM. Methods: This was a retrospective cohort study using the TriNetX database of 56741 patients with T2DM undergoing ECTR (N= 14,949) or OCTR (N= 41,792). Demographic data, medical comorbidities, and complication rates were analyzed. We used multivariable analysis to identify differences in postoperative complication rates between the two treatment methods in patients with T2DM. Results: Patients with T2DM undergoing ECTR had a significantly lower incidence of 90-day wound infection (p < 0.001), 90-day wound dehiscence (p < 0.001), and nerve injury (p < 0.001) when compared to patients who underwent OCTR. After matching, there was a significantly higher number of T2DM patients undergoing ECTR who had peripheral vascular disease (p = 0.045) and hypertension (p = 0.020) when compared to the OCTR group. These patients also had a lower incidence of fluid and electrolyte disorders (p = 0.002) and chronic blood loss anemia (p = 0.025). Conclusion: ECTR presents a superior choice for T2DM patients undergoing CTR, yielding significantly lower rates of wound infection, wound dehiscence, and nerve injury within 90 days post-surgery—reducing the risk by 31%, 48%, and 59%, respectively. These findings support the adoption of ECTR as the preferred method in this patient population, potentially leading to improved postoperative outcomes.

Keywords: endoscopic treatment of carpal tunnel syndrome, open treatment of carpal tunnel syndrome, carpal tunnel syndrome, postoperative complications in patients with diabetes mellitus

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Authors: Theresa Bacon-Baguley, Martina Reinhold

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Introduction: The purpose of this paper is to discuss the importance of both formative and summative evaluation of a Physician Assistant (PA) program with a distant campus delivered through Interactive Television (ITV) to assure equity of educational experiences. Methodology: A needs assessment utilizing a case-control design determined the need and interest in expanding the existing PA program to northern Michigan. A federal grant was written and funded, which supported the hiring of two full-time faculty members and support staff at the distant site. The strengths and weaknesses of delivering a program through ITV were evaluated using weekly formative evaluation, and bi-semester summative evaluation. Formative evaluation involved discussion of lecture content to be delivered, special ITV needs, orientation of new lecturers to the system, student concerns, support staff updates, and scheduling of student/faculty traveling between the two campuses. The summative evaluation, designed from a literature review of barriers to ITV, included 19 statements designed to evaluate the following items: quality of technology (audio, video, etc.), confidence in the ITV system, quality of instruction and instructor interaction between the two locations, and availability of resources at each location. In addition, students were given the opportunity to write qualitative remarks for each course delivered between the two locations. This summative evaluation was given to all students at mid-semester and at the end of the semester. The goal of the summative evaluation was to have 80% or greater of the students respond favorably (‘Very Good’ or ‘Good’) to each of the 19 statements. Results: Prior to the start of the first cohort at the distant campus, the technology was tested. During this time period, the formative evaluations identified key components needing modification, which were rapidly addressed: ability to record lectures, lighting, sound, and content delivery. When the mid-semester summative survey was given to the first cohort of students, 18 of the 19 statements in the summative evaluation met the goal of 80% or greater in the favorable category. When the summative evaluation statements were stratified by the two cohorts, the summative evaluation identified that students at the home location responded that they did not have adequate access to printers, and students at the expansion location responded that they did not have adequate access to library resources. These results allowed the program to address the deficiencies through contacting informational technology for additional printers, and to provide students with knowledge on how to access library resources. Conclusion: Successful expansion of programs to a distant site utilizing ITV technology requires extensive monitoring using both formative and summative evaluation. The formative evaluation allowed for quick identification of issues that could immediately be addressed, both at the planning and developing stage, as well as during implementation. Through use of the summative evaluation the program is able to monitor the success/ effectiveness of the expansion and identify specific needs of students at each location.

Keywords: assessment, distance learning, formative feedback, interactive television (ITV), student experience, summative feedback, support

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Authors: Yin-Yee Leong, Jack C. Yue, Hsin-Chung Wang

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Human longevity has been experiencing its largest increase since the end of World War II, and modeling the mortality rates is therefore often the focus of many studies. Among all mortality models, the Lee–Carter model is the most popular approach since it is fairly easy to use and has good accuracy in predicting mortality rates (e.g., for Japan and the USA). However, empirical studies from several countries have shown that the age parameters of the Lee–Carter model are not constant in time. Many modifications of the Lee–Carter model have been proposed to deal with this problem, including adding an extra cohort effect and adding another period effect. In this study, we propose a spatial modification and use clusters to explain why the age parameters of the Lee–Carter model are not constant. In spatial analysis, clusters are areas with unusually high or low mortality rates than their neighbors, where the “location” of mortality rates is measured by age and time, that is, a 2-dimensional coordinate. We use a popular cluster detection method—Spatial scan statistics, a local statistical test based on the likelihood ratio test to evaluate where there are locations with mortality rates that cannot be described well by the Lee–Carter model. We first use computer simulation to demonstrate that the cluster effect is a possible source causing the problem of the age parameters not being constant. Next, we show that adding the cluster effect can solve the non-constant problem. We also apply the proposed approach to mortality data from Japan, France, the USA, and Taiwan. The empirical results show that our approach has better-fitting results and smaller mean absolute percentage errors than the Lee–Carter model.

Keywords: mortality improvement, Lee–Carter model, spatial statistics, cluster detection

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Authors: Balasooriya B. M. C. M., Sujeeva N., Thowfeek Z., Siddiqa Omo, Liyanagunawardana J. E., Jayawardana Saiu, Manathunga S. S., Katulanda G. W.

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Introduction and objectives: Adrenal venous sampling (AVS) is the gold standard to discriminate unilateral primary aldosteronism (UPA) from bilateral disease (BPA). AVS is technically demanding and only performed in a limited number of centers worldwide. To the best of our knowledge, Except for one study conducted in India, no other research studies on this area have been conducted in South Asia. This study aimed to evaluate the effectiveness of AVS in the management of primary aldosteronism. Methods: A total of 32 patients who underwent AVS at the National Hospital of Sri Lanka from April 2021 to April 2023 were enrolled. Demographic, clinical and laboratory data were obtained retrospectively. A procedure was considered successful when adequate cannulation of both adrenal veins was demonstrated. Cortisol gradient across the adrenal vein (AV) and the peripheral vein was used to establish the success of venous cannulation. Lateralization was determined by the aldosterone gradient between the two sides. Continuous and categorical variables were summarized with mean, SD, and proportions, respectively. The mean and standard deviation of the contralateral suppression index (CSI) were estimated with an intercept-only Bayesian inference model. Results: Of the 32 patients, the average age was 52.47 +26.14 and 19 (59.4%) were males. Both AVs were successfully cannulated in 12 (37.5%). Among them, lateralization was demonstrated in 11(91.7%), and one was diagnosed as a bilateral disease. There were no total failures. Right AV cannulation was unsuccessful in 18 (56.25%), of which lateralization was demonstrated in 9 (50%), and others were inconclusive. Left AV cannulation was unsuccessful only in 2 (6.25%); one was lateralized, and the other remained inconclusive. The estimated mean of the CSI was 0.33 (89% credible interval 0.11-0.86). Seven patients underwent unilateral adrenalectomy and demonstrated significant improvement in blood pressure during follow-up. Two patients await surgery. Others were treated medically. Conclusions: Despite failure due to procedural difficulties, AVS remained useful in the management of patients with PA. Moreover, the success of the procedure needs experienced hands and advanced equipment to achieve optimal outcomes in PA.

Keywords: adrenal venous sampling, lateralization, contralateral suppression index, primary aldosteronism

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Authors: Fitsumbrhan Tajebe, Fadil Murad, Mitikie Tigabie, Mareye Abebaw, Tadele Alemu, Sefanit Abate, Rezika Mohammedw, Arega Yeshanew, Elias Shiferaw

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Background: Visceral leshimaniasis is a parasitic disease characterized by a systemic infection of phagocytic cells. Hematological parameters of these patients may be affected by the progress of the disease or treatment. Thus, the current study aimed to assess the hematological profiles of visceral leishmaniasis patients before and after treatment. Method: An institutional based retrospective cohort study was conducted among visceral leishmaniasis patients at University of Gondar Comprehensive Specialized Referral Hospital Leishmaniasis Research and Treatment Center from 2013 to 2018. Hematological profiles before initiation and after completion of treatment were extracted from registration book. Descriptive statics was presented using frequency and percentage. Paired t-test and Wilcoxon Signed rank test were used for comparing mean difference for normally and non- normally distributed data, respectively. Spearman and Pearson correlation analysis was used to describe the correlation of hematological parameters with different variables. P value < 0.05 was considered as statistically significant. Result: Except absolute nerutrophil count, post treatment hematological parameters show a significant increment compared to pretreatment one. The prevalence of anemia, leucopenia and thrombocytopenia was 85.5%, 83.4% and 75.8% prior to treatment and it was 58.3%, 38.2% and 19.2% after treatment, respectively. Moreover, parasite load of the disease showed statistically significant negative correlation with hematological profiles mainly with white blood cell and red blood cell. Conclusion: Majority of hematological profiles of patients with active VL have been restored after treatment, which might be associated with treatment effect on parasite proliferation and concentration of parasite in visceral organ, which directly affect hematological profiles.

Keywords: visceral leshimaniasis, hematological profile, anti-leshimanial drug, Gondar

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Authors: Avirup Chowdhury, Angus K. McFadyen, Linsey Batchelor

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Blood cultures (BCs) are an important aspect of management of the septic patient, identifying the underlying pathogen and its antibiotic sensitivities. However, while the current literature outlines indications for initial BCs to be taken, there is little guidance for repeat sampling in the following 5-day period and little information on how antibiotic use can affect the usefulness of this investigation. A retrospective cohort study was conducted using inpatients who had undergone 2 or more BCs within 5 days between April 2016 and April 2017 at a 400-bed hospital in the west of Scotland and received antibiotic therapy between the first and second BCs. The data for BC sampling was collected from the electronic microbiology database, and cross-referenced with data from the hospital electronic prescribing system. Overall, 283 BCs were included in the study, taken from 92 patients (mean 3.08 cultures per patient, range 2-10). All 92 patients had initial BCs, of which 83 were positive (90%). 65 had a further sample within 24 hours of commencement of antibiotics, with 35 positive (54%). 23 had samples within 24-48 hours, with 4 (17%) positive; 12 patients had sampling at 48-72 hours, 12 at 72-96 hours, and 10 at 96-120 hours, with none positive. McNemar’s Exact Test was used to calculate statistical significance for patients who received blood cultures in multiple time blocks (Initial, < 24h, 24-120h, > 120h). For initial vs. < 24h-post BCs (53 patients tested), the proportion of positives fell from 46/53 to 29/53 (one-tailed P=0.002, OR 3.43, 95% CI 1.48-7.96). For initial vs 24-120h (n=42), the proportions were 38/42 and 4/42 respectively (P < 0.001, OR 35.0, 95% CI 4.79-255.48). For initial vs > 120h (n=36), these were 33/36 and 2/36 (P < 0.001,OR ∞). These were also calculated for a positive in initial or < 24h vs. 24-120h (n=42), with proportions of 41/42 and 4/42 (P < 0.001, OR 38.0, 95% CI 5.22-276.78); and for initial or < 24h vs > 120h (n=36), with proportions of 35/36 and 2/36 respectively (P < 0.001, OR ∞). This data appears to show that taking an initial BC followed by a BC within 24 hours of antibiotic commencement would maximise blood culture yield while minimising the risk of false negative results. This could potentially remove the need for as many as 46% of BC samples without adversely affecting patient care. BC yield decreases sharply after 48 hours of antibiotic use, and may not provide any clinically useful information after this time. Further multi-centre studies would validate these findings, and provide a foundation for future health policy generation.

Keywords: antibiotics, blood culture, efficacy, inpatient

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Authors: Berihun Dachew, Abdullah Mamun, Joemer Maravilla, Rosa Alati

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Background: Hypertensive disorders of pregnancy are a major cause of maternal and childhood morbidity and mortality worldwide. However, its effect on offspring mental and behavioural disorders is unclear. Aims:The aim of this study was to provide the best scientific evidence regarding the association between hypertensive disorders of pregnancy and offspring mental and behavioural problems. Methods: We systematically searched Scopus, PubMed, Cochrane, EMBASE, CINAH and PsycINFO databases. A total of 23 studies (11 included in meta-analysis) were identified. A qualitative analysis was conducted by summarizing, comparing, and contrasting the abstracted data for all included studies. For quantitative analysis, relative risk (RR) with 95% confidence interval (95% CI) was used as pooled effect size. Heterogeneity was assessed by measuring Cochran’s Q and I2 test statistics. Results: Of the 23 studies included in this review, 15 studies found that hypertensive disorders of pregnancy had a negative impact for at least one mental or behavioural problem. The pooled effect of 11 studies included in the meta-analysis showed that preeclampsia was associated with increased risk of offspring schizophrenia (RR=1.37; 95% CI, 1.08-1.72). Conclusions: Intrauterine exposure to pre-eclampsia increased the risk of schizophrenia among offspring. However, we found inconclusive finding on the effect of hypertensive disorders of pregnancy and other mental and behavioural problems. Further high quality, large sample, mother child cohort studies are needed to further progress this area of research.

Keywords: behavioural disorders, hypertensive disorders of pregnancy, mental disorders, offspring

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Authors: Syahrul Bariah Abdul Hamid, Colin W. Binns, Jun Hui Chih

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The total of obese mothers is growing throughout Asia. Breastfeeding provides the perfect nutrition for infants, by promoting a higher IQ and protecting against childhood and adult diseases. A prospective cohort study was carried out of mothers attending eight antenatal clinics run by the Ministry of Health in Selangor, Malaysia to document the prevalence of obesity and its relationship with breastfeeding outcomes. Mothers were enrolled during the antenatal period and followed up until 6 months postpartum to document breastfeeding outcomes. A total of 652 Malay mothers were recruited for the study a response rate of 93.1 %. The pre-pregnancy body mass index (BMI) of the mothers showed that 36.5% of the mothers were overweight or obese. There were a total of 78 obese mothers in the sample and 41 (52.6%) of these mothers were able to initiate breastfeeding within one hour of birth compared to 238/337 (70.6 %, χ² 9.35, p<0.001) of those with a normal BMI. At 6 months, 23.1 % of obese mothers were exclusively breastfeeding their infants, compared to 56.0 % of the normal BMI mothers. On the other hand, the rate of infant formula feeding was higher in the obese mothers by 53.8 % compared to 19.0 % among normal weight mothers, χ² 37.6, p<0.001). Further analysis suggested these factors were found to be positively associated with discontinued exclusive breastfeeding at 6 months among obese mothers; mothers whom delayed breastfeeding initiation, had health problems during pregnancy, caesarean delivery, reported had insufficient colostrum/milk and babies had sucking problems at or before 4 weeks. Besides that, mothers who perceived their biological mothers had preference towards formula feeding or were ambivalent about the feeding method and had biological mothers without experience in breastfeeding for more than 1 month also were more likely to discontinue exclusive breastfeeding at 6 months. These findings suggested that the greater the pre-pregnant BMI, the earlier the cessation of exclusive breastfeeding and they were also less likely to initiate breastfeeding and have less adequate milk supply. Future investigations of the effects of maternal obesity on breastfeeding outcomes should be conducted along with effective interventions to advance the care of obese women at reproductive age and their children.

Keywords: exclusive breastfeeding, body mass index (BMI), breastfeeding discontinuation, maternal obesity

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Authors: Bindu I. Somarajan, Viney Gupta, Gagandeep Kaur Walia, Jasbir Kaur, Sunil Kumar, Shikha Gupta, Abadh K. Chaurasia, Dinesh Gupa, Abhinav Kaushik, Aditi Mehta, Vipin Gupta, Arundhati Sharma

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Background: Juvenile onset primary open angle glaucoma (JOAG), affects individuals under the age of 40 years. Studies on a few families of JOAG, that led to the discovery of the Myocilin gene, reported the disease to have an autosomal dominant pattern of inheritance. However, sporadic forms of JOAG been seen to be more common in some populations. Most pathological homozygous mutations in the CYP1B1 gene associated with JOAG have been seen among sporadic cases. Given the higher prevalence of sporadic JOAG cases in our population, we aimed to look for common mutations E229K and R368H, the two most common variants in the CYP1B1 gene associated with glaucoma. Objective: To determine the frequency and evaluate genotype phenotype correlation of CYP1B1 E229K and R368H mutations in a cohort of 120 sporadic Juvenile open angle glaucoma patients.Methods: Unrelated JOAG patients whose first degree relatives had been examined and found to be unaffected were included in the study. The patients and their parents were screened for E229K and R368H mutations. The phenotypic characteristics were compared between probands with and with out these mutations by SPSS v16. Results: Out of 120 JOAG patients included in the study, the E229K mutation was seen in 9 probands (7.5%) and R368H in 7 (5.8%). The average age of onset of the disease (p=0.3) and the highest untreated IOP (p=0.4) among those carrying mutations was not significantly different from those who did not have these mutations. The proportion of probands with angle dysgenesis among those with E229K and R368H mutations was 70% (11 out of 16) in comparison to 65% (67 out of 104) of those who did not harbour these mutations (p=0.56). Similarly the probands with moderate to high myopia among those with E229K and R368H mutations was 20% (3 out of 16) in comparison to 18% (18 out of 104) of those who did not harbour these mutations(p=0.59). Conclusion: The frequency of E229K and R368H mutations of the CYP1B1 gene is low even among sporadic JOAG patients. Moreover there is no clinical correlation between the presence of these mutations and disease severity

Keywords: CYP1B1, gene, IOP, JOAG, mutation

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Authors: Karimeh Alnuaimi, Manal Kassab, Reem Ali, Khitam Mohammad, Kholoud Shattnawi

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Aim: To compare pregnancy outcomes of Syrian refugee women and Jordanian women. Background and introduction: The current conflict in Syria continues to displace thousands to neighboring countries, including Jordan. Pregnant refugee women are therefore facing many difficulties are known to increase the prevalence of poor reproductive health outcomes and antenatal complications. However, there is very little awareness of whether Syrian refugee women have different risks of pregnancy outcomes than Jordanian women. Methods: Using a retrospective cohort design, we examined pregnancy outcomes for Syrian refugee (N = 616) and Jordanian women (N = 644) giving birth at two governmental Hospitals in the north of Jordan, between January 1, 2014, and December 31, 2014. A checklist of 13 variables was utilized. The primary outcome measures were delivery by Caesarean section, maternal complications, low birth weight (< 2500 g), Apgar score and preterm delivery (< 37 weeks' gestational age). Results: Statistical analysis revealed that refugee mothers had a significant increase in the rate of cesarean section and the higher rate of anemia, a lower neonates’ weight, and Apgar scores when compared to their Jordanian counterparts. Discussion and Conclusion: Results were congruent with findings from other studies in the region and worldwide. Minimizing inequalities in pregnancy outcomes between Syrian refugees and Jordan women is a healthcare priority. Implications for nursing and health policy: The findings could guide the planning and development of health policies in Jordan that would help to alleviate the situation regarding refugee populations. The action is required by the policy makers, specifically targeting public and primary health care services, to address the problem of adequately meeting the need for antenatal care of this vulnerable population.

Keywords: pregnancy, Syrian refugee, Jordanian women, comparative study

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Authors: Asish Subedi, Krishna Pokharel, Birendra Prasad Sah, Pashupati Chaudhary

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Objectives: To evaluate an association between preoperative Nepali pain catastrophizing scale (N-PCS) scores and postoperative pain intensity and total opioid consumption. Methods: In this prospective cohort study we enrolled 135 patients with an American Society of Anaesthesiologists physical status I or II, aged between 18 and 65 years, and scheduled for surgery for lower-extremity fracture under spinal anaesthesia. Maximum postoperative pain reported during the 24 h was classified into two groups, no-mild pain group (Numeric rating scale [NRS] scores 1 to 3) and a moderate-severe pain group (NRS 4-10). The Spearman correlation coefficient was used to compare the association between the baseline N-PCS scores and outcome variables, i.e., the maximum NRS pain score and the total tramadol consumption within the first 24 h after surgery. Logistic regression models were used to identify the predictors for the intensity of postoperative pain. Results: As four patients violated the protocol, the data of 131 patients were analysed. Mean N-PCS scores reported by the moderate-severe pain group was 27.39 ±9.50 compared to 18.64 ±10 mean N-PCS scores by the no-mild pain group (p<0.001). Preoperative PCS scores correlated positively with postoperative pain intensity (r =0.39, [95% CI 0.23-0.52], p<0.001) and total tramadol consumption (r =0.32, [95% CI 0.16-0.47], p<0.001). An increase in catastrophizing scores was associated with postoperative moderate-severe pain (odds ratio, 1.08 [95% confidence interval, 1.02-1.15], p=0.006) after adjusting for gender, ethnicity and preoperative anxiety. Conclusion: Patients who reported higher pain catastrophizing preoperatively were at increased risk of experiencing moderate-severe postoperative pain.

Keywords: nepali, pain catastrophizing, postoperative pain, trauma

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Authors: Janis E. Campbell

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Most of what is known about complementary, alternative or traditional medicine (CATM) in the United States today is known from either the National Health Interview Survey a cross-sectional survey with a few questions or from small cross-sectional or cohort studies with specific populations. The broad geographical distribution in CATM use or providers is not known. For this project, we used geospatial cluster analysis to determine if there were clusters of CATM provider by county in the US. In this analysis, we used the National Provider Index to determine the geographic distribution of providers in the US. Of the 215,769 CAMT providers 211,603 resided in the contiguous US: Acupuncturist (26,563); Art, Poetry, Music and Dance Therapist (2,752); Chiropractor (89,514); Doula/Midwife (3,535); Exercise (507); Homeopath (380); Massage Therapist (36,540); Mechanotherapist (1,888); Naprapath (146); Naturopath (4,782); Nutrition (42,036); Reflexologist (522); Religious (2,438). ESRI® spatial autocorrelation was used to determine if the geographic location of CATM providers were random or clustered. For global analysis, we used Getis-Ord General G and for Local Indicators of Spatial Associations with an Optimized Hot Spot Analysis using an alpha of 0.05. Overall, CATM providers were clustered with both low and high. With Chiropractors, focusing in the Midwest, religious providers having very small clusters in the central US, and other types of CAMT focused in the northwest and west coast, Colorado and New Mexico, the great lakes areas and Florida. We will discuss some of the implications of this study, including associations with health, economic, social, and political systems.

Keywords: complementary medicine, alternative medicine, geospatial, United States

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Authors: Nuttapimon Bhirommuang, Kulapong Jayanama

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Background: Prevalence of malnutrition in hospitalized patient is higher than general population. As a result of the unawareness of consequence and the more concerning in the other aspects of care, many patients with high risk of malnutrition are unrecognized. Even if malnutrition has been identified as affecting in many patient outcomes, the impact may differ in each population and group of patients. Objectives: The aims of this study were to examine the association between the nutritional status and the length of stay and hospital costs in hospitalized patients, to investigate the factors related these outcomes and to determine the frequency of malnutrition in hospitals. Method: This retrospective cohort study enrolled all patients aged 15 years old or older and admitted in SDMC, Ramathibodi Hospital between 1st January 2016 and 30th September 2016. The nutritional status assessment by Nutrition Alert Form (NAF) was performed by well-trained nurses in all patients at admission. Baseline characteristics were recorded. Length of stay and hospital costs were collected during their hospitalization. Univariate analysis, nonparametric rank test, Kruskal-Wallis test were used to compare means in the case of nonnormally and noncontinuously distributed data. Chi-square used to analyze categorical variables, the nutritional status and the length of stay and hospital costs and identify possible confounding factors (data were analyzed using SPSS version 18.0). Result: Of the 2,906 patients, 3.9% were severe malnutrition (NAF-C score > 10) and 11.4% were moderate malnutrition (NAF-B score 6 - 10). Both length of stay and hospital costs were found significantly higher in more severe malnutrition group (p < 0.001), NAF = A: 3.21 days, 95% CI 3.06-3.35 and 111,544.25 THB, 95% CI 106,994.41 – 116,094.1; NAF = B: 7.54 days, 95% CI 6.32 – 8.76 and 162,302.4 THB, 95% CI 129,557.88 – 195,046.92; NAF =C: 14.77 days, 95% CI 11.34 – 18.2 and 323,572.11 THB, 95% CI 226,958.1 – 420,096.13 (1 THB = 0.03019 USD). Age of each nutritional status group had also significant increase from NAF A to NAF C (p < 0.001): 55.07, 67.03 and 73.88 years old, respectively. Conclusion: The prevalence of malnutrition in Ramathibodi hospital is voluminous. Severe malnutrition screening by NAF is significantly correlated with worse clinical outcome, especially higher length of stay and hospital costs. Elderly is also a significant factor which correlates with malnutrition. The results of this study could change the awareness of health personnel and the practice protocol. Moreover, the further study concerning nutritional support in high-risk group of malnutrition is ongoing to confirm this hypothesis.

Keywords: malnutrition, NAF, length of stay, hospital costs

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Authors: S. Yeo, M. Mathur

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Introduction: Obesity, defined as a Body Mass Index (BMI) of more than or equal to 30kg/m, is associated with an increased risk of complications during pregnancy and delivery. During labour, obese mothers often require greater intervention and have higher rates of caesarean section. Despite a low overall rate of serious complications following caesarean section, a high BMI predisposes to a higher risk of postoperative complications. Our study, therefore, aimed to investigate the impact of antenatal obesity on adverse outcomes following caesarean section, particularly wound-related infections. Materials and Methods: A retrospective cohort study of all caesarean deliveries during the first quarter of a chosen year was undertaken in our hospital, which is a tertiary referral centre with > 12,000 deliveries per year. Patients’ health records and data from our hospital’s electronic labour and delivery database were reviewed. Data analysis was performed using the Statistical Package for the Social Sciences (SPSS), and odds ratios plus adjusted odd ratios were calculated with 95% confidence intervals (CI). Results: A total of 1829 deliveries were reviewed during our study period. Of these, 180 (9.8%) patients were obese. The rate of caesarean delivery was 48.9% in obese patients versus 28.1% in non-obese patients. Post-operatively, 17% of obese patients experienced wound infection versus 0.2% of non-obese patients. Obese patients were also more likely to experience major postpartum haemorrhage (4.6% vs. 0.2%) and postpartum pyrexia (18.2% vs. 5.0%) in comparison to non-obese patients. Conclusions: Obesity is a significant risk factor in the development of postoperative complications following caesarean section. Wound infection remains a major concern for obese patients undergoing major surgery and results in extensive morbidity during the postnatal period. Postpartum infection can prolong recovery and affect maternal mental health, leading to reduced perinatal bonding with long-term implications on breastfeeding and parenting confidence. This study supports the need for the development of standardized protocols specifically for obese patients undergoing caesarean section. Multidisciplinary team care, in conjunction with anaesthesia, family physicians, and plastic surgery counterparts, early on in the antenatal journey, may be beneficial where wound complications are anticipated and to minimize the burden of postoperative infection in obese mothers.

Keywords: pregnancy, obesity, caesarean, infection

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Authors: Mina Hojat Ansari, Kamran Bagheri Lankarani, Mohammad Reza Fattahi, Ali Reza Safarpour

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Irritable bowel syndrome (IBS) is a common bowel disorder which is usually diagnosed through the abdominal pain, fecal irregularities and bloating. Alteration in the intestinal microbial composition is implicating to inflammatory and functional bowel disorders which is recently also noted as an IBS feature. Owing to the potential importance of microbiota implication in both efficiencies of the treatment and prevention of the diseases, we examined the association between the intestinal microbiota and different bowel patterns in a cohort of subjects with IBS and healthy controls. Fresh fecal samples were collected from a total of 50 subjects, 30 of whom met the Rome IV criteria for IBS and 20 Healthy control. Total DNA was extracted and library preparation was conducted following the standard protocol for small whole genome sequencing. The pooled libraries sequenced on an Illumina Nextseq platform with a 2 × 150 paired-end read length and obtained sequences were analyzed using several bioinformatics programs. The majority of sequences obtained in the current study assigned to bacteria. However, our finding highlighted the significant microbial taxa variation among the studied groups. The result, therefore, suggests a significant association of the microbiota with symptoms and bowel characteristics in patients with IBS. These alterations in fecal microbiota could be exploited as a biomarker for IBS or its subtypes and suggest the modification of the microbiota might be integrated into prevention and treatment strategies for IBS.

Keywords: irritable bowel syndrome, intestinal microbiota, small whole genome sequencing, fecal samples, Illumina

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Authors: Noman Shahzad, Amyn Pardhan, Hasnain Zafar

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Introduction: Though short term survival advantage of damage control laparotomy in management of critically ill trauma patients is established, there is little known about the long-term quality of life of these patients. Facial closure rate after damage control laparotomy is reported to be 20-70 percent. Abdominal wall reconstruction in those who failed to achieve facial closure is challenging and can potentially affect quality of life of these patients. Methodology: We conducted retrospective matched cohort study. Adult patients who underwent damage control laparotomy from Jan 2007 till Jun 2013 were identified through medical record. Patients who had concomitant disabling brain injury or limb injuries requiring amputation were excluded. Age, gender and presentation time matched non exposure group of patients who underwent laparotomy for trauma but no damage control were identified for each damage control laparotomy patient. Quality of life assessment was done via telephonic interview at least one year after the operation, using Urdu version of EuroQol Group Quality of Life (QOL) questionnaire EQ5D after permission. Wilcoxon signed rank test was used to compare QOL scores and McNemar test was used to compare individual parameters of QOL questionnaire. Study was approved by institutional ethical review committee. Results: Out of 32 patients who underwent damage control laparotomy during study period, 20 fulfilled the selection criteria for which 20 matched controls were selected. Median age of patients (IQ Range) was 33 (26-40) years. Facial closure rate in damage control laparotomy group was 40% (8/20). One third of those who did not achieve facial closure (4/12) underwent abdominal wall reconstruction. Self-reported QOL score of damage control laparotomy patients was significantly worse than non-damage control group (p = 0.032). There was no statistically significant difference in two groups regarding individual QOL measures. Significantly, more patients in damage control group were requiring use of abdominal binder, and more patients in damage control group had to either change their job or had limitations in continuing previous job. Our study was not adequately powered to detect factors responsible for worse QOL in damage control group. Conclusion: Quality of life of damage control patients is worse than their age and gender matched patients who underwent trauma laparotomy but not damage control. Adequately powered studies need to be conducted to explore factors responsible for this finding for potential improvement.

Keywords: damage control laparotomy, laparostomy, quality of life

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Authors: Franziska Köhler-Dauner, Inka Mayer, Lara Hart, Ute Ziegenhain, Jörg M. Fegert

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Preventive isolation and social distancing strategies during the SARS-CoV-2 pandemic have confronted families with a variety of different restrictions and stresses. Especially during this stressful time, children need a stable parental home to avoid developmental disorders. Additional risk factors such as maternal childhood abuse and neglect (CM) experiences may influence mothers' psychosomatic health (pG) and children's physical well-being (kW) during times of increased stress. Our aim was to analyse the interaction between maternal CM, maternal pG and children's kW during the pandemic. Mothers from a well-documented birth cohort to study transgenerational transmission of CM, were included in an online 'pandemic' survey assessing maternal pG and children's physical health during the pandemic. Our mediation analysis showed a significant positive association between the extent of maternal CM experiences, mothers' psychosomatic symptoms and their children's kW. Maternal psychosomatic symptoms significantly mediate the interaction between CM and children's kW; the direct effect remains non-significant when maternal psychosomatic symptoms are included as mediators. Maternal CM appears to be a relevant risk factor for maternal pG and children's kW during the pandemic. Maternal CM experiences seem to influence the way parents cope with stressful situations and increase the risk of suffering from depressive symptoms. The latter also affect their children's kW. Our findings underline the importance of carefully assessing the specific situation of families with children and offering individually adapted help to help families survive the pandemic.

Keywords: pandemic, maternal health, child health, abuse, neglect, maternal experiences

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Authors: Avani Jain, S. Shelley, M. Indirani, Shilpa Kalal, Jaykanth Amalachandran

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Aim: To evaluate the prevalence of gall bladder dysfunction in patients with dyspepsia using In-House fatty meal cholescintigraphy. Materials & Methods: This study is a prospective cohort study. 59 healthy volunteers with no dyspeptic complaints and negative ultrasound and endoscopy were recruited in study. 61 patients having complaint of dyspepsia for duration of more than 6 months were included. All of them underwent 99mTc-Mebrofenin fatty meal cholescintigraphy following a standard protocol. Dynamic acquisitions were acquired for 120 minutes with an In-House fatty meal being given at 45th minute. Gall bladder emptying kinetics was determined with gall bladder ejection fractions (GBEF) calculated at 30minutes, 45minutes and at 60 minutes (30min, 45min & 60 min). Standardization of fatty meal was done for volunteers. Receiver operating characteristic (ROC) analysis was used assess the diagnostic accuracy of 3 time points (30min, 45min & 60 min) used for measuring gall bladder emptying. On the basis of cut off derived from volunteers, the patients were assessed for gall bladder dysfunction. Results: In volunteers, the GBEF at 30 min was 74.42±8.26 % (mean ±SD), at 45 min was 82.61 ± 6.5 % and at 60 min was 89.37±4.48%, compared to patients where at 30min it was 33.73±22.87%, at 45 min it was 43.03±26.97% and at 60 min it was 51.85±29.60%. The lower limit of GBEF in volunteers at 30 min was 60%, 45 min was 69% and at 60 min was 81%. ROC analysis showed that area under curve was largest for 30 min GBEF (0.952; 95% CI = 0.914-0.989) and that all the 3 measures were statistically significant (p < 0.005). Majority of the volunteers had 74% of gall bladder emptying by 30 minutes; hence it was taken as an optimum cutoff time to assess gall bladder contraction. > 60% GBEF at 30 min post fatty meal was considered as normal and < 60% GBEF as indicative of gall bladder dysfunction. In patients, various causes for dyspepsia were identified: GB dysfunction (63.93%), Peptic ulcer (8.19 %), Gastroesophageal reflux disease (8.19%), Gastritis (4.91%). In 18.03% of cases GB dysfunction coexisted with other gastrointestinal conditions. The diagnosis of functional dyspepsia was made in 14.75% of cases. Conclusions: Gall bladder dysfunction contributes significantly to the causation of dyspepsia. It could coexist with various other gastrointestinal diseases. Fatty meal was well tolerated and devoid of any side effects. Many patients who are labeled as functional dyspeptics could actually have gall bladder dysfunction. Hence as an adjunct to ultrasound and endoscopy, fatty meal cholescintigraphy can also be used as a screening modality in characterization of dyspepsia.

Keywords: in-house fatty meal, choescintigraphy, dyspepsia, gall bladder ejection fraction, functional dyspepsia

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Authors: Eun Jeong Yu, Inn Soo Kang, Tae Ki Yoon, Mi Kyoung Koong

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Advanced female age is associated with higher cycle cancelation rates, lower clinical pregnancy rate, increased miscarriage and aneuploidy rates in IVF (In Vitro Fertilization) cycles. This retrospective cohort study was conducted at a Cha Fertility Center, Seoul Station. All fresh non-donor IVF cycles performed in women aged 40 years and above from January 2016 to December 2016 were reviewed. Donor/recipient treatment, PGD/PGS (Preimplantation Genetic Diagnosis/ Preimplantation Genetic Screening) were excluded from analysis. Of the 1,166 cycles from 753 women who completed ovulation induction, 1,047 were appropriate for the evaluation according to inclusion and exclusion criterion. IVF cycles were categorized according to age and grouped into the following 1-year age groups: 40, 41, 42, 43, 44, 45 and > 46. The mean age of patients was 42.4 ± 1.8 years. The median AMH (Anti-Mullerian Hormone) level was 1.2 ± 1.5 ng/mL. The mean number of retrieved oocytes was 4.9 ± 4.3. The clinical pregnancy rate and live birth rate in women > 40 years significantly decreased with each year of advancing age (p < 0.001). The clinical pregnancy rate decreased from 21% at the age of 40 years to 0% at ages above 45 years. Live birth rate decreased from 12.3% to 0%, respectively. There were no clinical pregnancy outcomes among 95 patients aged above 45 years of age. The overall miscarriage rate was 40.7% (range, 36.7%-70%). The transfer of at least one good quality embryo was associated with about 4-9% increased chance of a clinical pregnancy rate. Therefore, IVF in old age women less than 46 had a reasonable chance for successful pregnancy outcomes especially when good quality embryo is transferred.

Keywords: advanced maternal age, in vitro fertilization, pregnancy rate, live birth rate

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Authors: Mokgophana Ramasobana

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Background: At the core of the demand to utilize evidence-based approaches in the policy-making cycle, prioritization of limited financial resources and results driven initiatives is the urgency to develop a cohort of competent Monitoring and Evaluation (M&E) practitioners and public servants. The ongoing strides in the evaluation capacity building (ECB) initiatives are a direct response to produce the highly-sought after M&E skills. Notwithstanding the rapid growth of M&E short courses, participants perceived value and expectation of M&E short courses as a panacea for ECB have not been empirically quantified or measured. The objective of this article is to explicitly illustrate the importance of measuring ECB interventions and understanding what works in ECB and why it works. Objectives: This article illustrates the importance of establishing empirical ECB measurement tools to evaluate ECB interventions in order to ascertain its contribution to the broader evaluation practice. Method: The study was primarily a desktop review of existing literature, juxtaposed by a survey of the participants across the African continent based on the 43 M&E short courses hosted by the Centre for Learning on Evaluation and Results Anglophone Africa (CLEAR-AA) in collaboration with the Department of Planning Monitoring and Evaluation (DPME) Results: The article established that participants perceive short course training as a panacea to improve their M&E practical skill critical to executing their organizational duties. In tandem, participants are likely to demand customized training as opposed to general topics in Evaluation. However, the organizational environments constrain the application of the newly acquired skills. Conclusion: This article aims to contribute to the 'how to' measure ECB interventions discourse and contribute towards the improvement to evaluate ECB interventions. The study finds that participants prefer training courses with longer duration to cover more topics. At the same time, whilst organizations call for customization of programmes, the study found that individual participants demand knowledge of generic and popular evaluation topics.

Keywords: evaluation capacity building, effectiveness and training, monitoring and evaluation (M&E) short course training, perceptions and expectations

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Authors: Nowrozy Jahan, Sharifah Syed Hassan, Daniel Reidpath

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In recent decades, Malaysia has become a dengue hyper-endemic country with the co-circulation of the four-dengue virus (DENV) serotypes. The number of symptomatic dengue cases is maintaining an increasing trend since 1995 and sharply increased in 2014. The four DENV serotypes have been co-circulating since 2000, and this pattern of cyclical dominance of sub-types contributed to the development of frequent major dengue epidemics in Malaysia. Since 2012, different Malaysian state was dominated by different serotypes. The study aims to estimate the burden of asymptomatic dengue in a healthy adult population which may act as a potential source of further symptomatic dengue infection. It also aims to identify the predominant DENV serotypes which are circulating at the community level. A longitudinal prospective community-based study was conducted in the Segamat district of Johor State, southern part of Malaysia where the number of reported dengue cases has steadily increased over the last three years (2013-2015). More specifically, the study was conducted in and around of Kampung Abdullah of Sungai Segamat sub-district which was identified as a hot spot area over the period of 2013-2015. This community-based study has been conducted by Southeast Asia Community Observatory (SEACO), an ISO-certified research platform in collaboration of the Ministry of Health Malaysia and Monash University Malaysia. It was conducted from May 2015 to May 2016. In this study, 277 apparently looking healthy respondents joined who were followed up as a cohort for four times during the one-year study period. Blood was collected to detect the serological marker of dengue at each round of follow-up. Among 277, 184 respondents (66%) joined all four rounds. Half of the study respondents were at the age-group of 45-64 years, slightly more than half of the respondents (59%) were female, and the most (69%) of them were Malay; only 35% lived in urban areas. During the baseline, the study found a very high prevalence of exposure to dengue virus; 89% of the study respondents had serological evidence of previous asymptomatic dengue infection; the majority of them did not know about it as they did not develop any symptom of dengue fever; only 13% knew as they developed symptoms. At the end of the one-year study period, 19% of respondents developed recent secondary dengue infection which was also identified by the serological marker as they did not develop any symptom (asymptomatic cases). The asymptomatic dengue incidence was higher during the rainy season compared to the dry season. All four dengue serotypes were identified in the serum of the infected respondents; among them, DENV-2 was the most prominent. Further genetic analysis is going on to identify the association of HLA-B*46 and HLA-DRB1*08 with dengue resistance. This study provides evidence for the policymakers to be aware of asymptomatic dengue infection, to develop a useful tool for raising awareness about asymptomatic dengue infection among the general population, to monitor the community participation to strengthen the individual and community level dengue prevention and control measures when neither there is vaccine nor particular treatment for dengue.

Keywords: asymptomatic, dengue, health adults, prospective study

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Authors: Cherrie Mae S. Sia, Noel J. Belonguel, Jarungchai Anton S. Vatanagul

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Background: Parkinson’s disease (PD) is a chronic progressive, neurodegenerative disorder known for its motor symptoms such as bradykinesia, resting tremor, muscle rigidity, and postural instability. Patients with PD also experience non-motor symptoms (NMS) such as depression, fatigue, and sleep disturbances that are most of the time unrecognized by clinicians. This may be due to the lack of spontaneous reports from the patients or partly because of the lack of systematic questioning from the healthcare professional. There is limited data with regards to these NMS especially that of Filipino patients with PD. Objectives: This study aims to determine the non-motor symptoms of Filipino patients with Parkinson’s disease. Materials and Methods: This is a prospective, cohort study involving thirty-four patients of Filipino-descent diagnosed with PD in three out-patient clinics in Cebu City from April to September 2014. Each patient was interviewed using the Non-Motor Symptom Scale (NMSS). A Cebuano version of the NMSS was also provided for the non-English speaking patients. Interview time was approximately ten to fifteen minutes for each respondent. Results: Of the thirty-four patients with Parkinson’s disease, majority was noted to be males (N=19) and the disease was noted to be more prevalent in patients with a mean age of 62 (SD±9) years old. Hypertension (59%) and diabetes mellitus (29%) were the common co-morbidities in the study population. All patients presented more than one NMS, with insomnia (41.2%), poor memory (23.5%) and depression (14.7%) being the first non-motor symptoms to occur. Symptoms involving mood/cognition (mean=2.21), and attention/memory (mean=2.05) were noted to be the most frequent and of moderate severity. Based on the NMSS, the symptoms that were noted to be mild and often to occur were those that involved the mood/cognition (score=3.84), attention/memory (score=3.50), and sleep/fatigue (score=3.00) domains. Levodopa-Carbidopa, Ropinirole, and Pramipexole were the most frequently used medications in the study population. Conclusion: Non-motor symptoms (NMS) are common in patients with Parkinson’s disease (PD). They appear at the time of diagnosis of PD or even before the motor symptoms manifest. The earliest non-motor symptoms to occur are insomnia, poor memory, and depression. Those pertaining to mood/cognition and attention/memory are the most frequent NMS and they are of moderate severity. Identifying these NMS by doing a questionnaire-guided interview such as the Non-Motor Symptom Scale (NMSS) before they can become more severe and affect the patient’s quality of life is a must for every clinician caring for a PD patient. Early treatment and control of these NMS can then be given, hence, improving the patient’s outcome and prognosis.

Keywords: non motor symptoms, Parkinson's Disease, insomnia, depression

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Authors: Maria Giovanna Lupo, Marina Camera, Marcello Rattazzi, Nicola Ferri

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A complex interplay among chronic kidney disease, lipid metabolism and aortic calcification has been recognized starting from results of many clinical and experimental studies. Here we investigated the influence of kidney function on PCSK9 levels, both in uremic rats and in clinical observation study, and its potential direct action on cultured smooth muscle cells (SMCs) calcification. In a cohort of 594 subjects enrolled in a single centre, observational, cross-sectional and longitudinal study, a negative association between GFR and plasma PCSK9 was found. Atherosclerotic cardiovascular disease (ASCVD), as co-morbidity, further increased PCSK9 plasma levels. Diet-induced uremic condition in rats, induced aortic calcification and increased total cholesterol and PCSK9 levels in plasma, livers and kidneys. Immunohistochemical analysis confirmed PCSK9 expression in aortic SMCs. SMCs overexpressing PCSK9 (SMCsPCSK9), cultured for 7-days in a pro-calcification environment (2.0mM or 2.4mM inorganic phosphate, Pi) showed a significantly higher extracellular calcium (Ca2+) deposition compared to mocked SMCs. Under the same experimental conditions, the addition of exogenous recombinant PCSK9 did not increase the extracellular calcification of SMCs. By flow cytometry analysis we showed that SMCsPCSK9, in response to 2.4mM Pi, released higher number of extracellular vesicles (EVs) positive for three tetraspanin molecules, such as CD63, CD9, and CD81. EVs derived from SMCsPCSK9 tended to be more enriched in calcium and alkaline phosphatase (ALPL), compared to EVs from mocks SMCs. In conclusion, our study reveals a direct role of PCSK9 on vascular calcification induced by higher inorganic phosphate levels associated to CKD condition. This effect appears to be mediated by a positive effect of endogenous PCSK9 on the release of EVs containing Ca2+ and ALP, which facilitate the deposition inorganic calcium phosphate crystals.

Keywords: PCSK9, calcification, extracellular vesicles, chronic kidney disease

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Authors: Mardiana Madjid, Nurpudji Astuti Taslim, Suryani As'ad, Haerani Rasyid, Agussalim Bukhari

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The high level of Urine Urea Nitrogen (UUN) indicates hypercatabolism occurs in hospitalized patients. High levels of Total Lymphocyte Count (TLC) indicates the immune system condition, adequate wound healing, and limit complication. Adequate dietary intake affects to decrease of hypercatabolism status in treated patient’s hospitals. Nitrogen Balance (NB) is simply the difference between nitrogen (N₂) intake and output. If more N₂ intake than output, then positive NB or anabolic will occur. This study aims to evaluate the effect of dietary intake in influencing balance nitrogen and total lymphocyte count. Method: A total of 43 patients admitted to a Wahidin Sudirohusodo Hospital between 2018 and 2019 for 10 days' treats are included. The inclusion criteria were patients who were treated for 10 days and receives food from the hospital orally. Patients did not experience gastrointestinal disorders such as vomiting and diarrhea and experience impair kidney function and liver function and expressed approval to participate in this study. During hospitalization, food intake, UUN, albumin serum, balance nitrogen, and TLC was assessed twice on day 1 and day 10. There is no Physician Clinical Nutritional intervention to correct food intake. UUN is 24 hours of urine collected on the second day after admission and the tenth day. Statistical analysis uses SPSS 24 with observational cohort methods. Result: The Forty-three participants completed the follow-up (27 men and 18 women). The age of fewer than 4 years is 22 people, 45 to 60 years is 16 people, and over 60 years is 4 people. The result of the study on day 1 obtained SGA score A, SGA score B, SGA score C are 8, 32, 3 until day 10 are 8, 31, 4, respectively. According to 24h dietary recalls, the energy intake during observation was from 522.5 ± 400.4 to 1011.9 ± 545.1 kcal/day P < 0.05, protein intake from 20.07 ± 17.2 to 40.3 ± 27.3 g/day P < 0.05, carbohydrates from 92.5 ± 71.6 to 184.8 ± 87.4 g/day, and fat from 5.5 ± 3.86 to 13.9 ± 13.9 g/day. The UUN during the observation was from 6.6 ± 7.3 to 5.5 ± 3.9 g/day, TLC decreased from 1622.9 ± 897.2 to 1319.9 ± 636.3/mm³ value target 1800/mm³, albumin serum from 3.07 ± 0.76 to 2.9 ± 0.57 g/day, and BN from -7.5 ± 7.2 to -3.1 ± 4.86. Conclusion: The high level of UUN needs to correct adequate dietary intake to improve NB and TLC status on hospitalized patients.

Keywords: adequate dietary intake, balance nitrogen, total lymphocyte count, urine urea nitrogen

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Authors: Getahun Nigusie Demise

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Background; antiretroviral treatment reduce HIV-related morbidity, and prolonged survival of patients however, there is lack of up-to-date information concerning the treatment long term effect on the survival of HIV positive children especially in the study area. Objective: The aim of this study is to assess the incidence and predictors of mortality among HIV positive children on antiretroviral therapy (ART) in public hospitals of Harer town who were enrolled from 2011 to 2021. Methodology: Institution based retrospective cohort study was conducted among 429 HIV positive children enrolled in ART clinic from January 1st 2011 to December30th 2021. Data were collected from medical cards by using a data extraction form, Descriptive analyses were used to Summarized the results, and life table was used to estimate survival probability at specific point of time after introduction of ART. Kaplan Meier survival curve together with log rank test was used to compare survival between different categories of covariates, and Multivariate Cox-proportional hazard regression model was used to estimate adjusted Hazard rate. Variables with p-values ≤0.25 in bivariable analysis were candidates to the multivariable analysis. Finally, variables with p-values < 0.05 were considered as significant variables. Results: The study participants had followed for a total of 2549.6 child-years (30596 child months) with an overall mortality rate of 1.5 (95% CI: 1.1, 2.04) per 100 child-years. Their median survival time was 112 months (95% CI: 101–117). There were 38 children with unknown outcome, 39 deaths, and 55 children transfer out to different facility. The overall survival at 6, 12, 24, 48 months were 98%, 96%, 95%, 94% respectively. being in WHO clinical Stage four (AHR=4.55, 95% CI:1.36, 15.24), having anemia(AHR=2.56, 95% CI:1.11, 5.93), baseline low absolute CD4 count (AHR=2.95, 95% CI: 1.22, 7.12), stunting (AHR=4.1, 95% CI: 1.11, 15.42), wasting (AHR=4.93, 95% CI: 1.31, 18.76), poor adherence to treatment (AHR=3.37, 95% CI: 1.25, 9.11), having TB infection at enrollment (AHR=3.26, 95% CI: 1.25, 8.49),and no history of change their regimen(AHR=7.1, 95% CI: 2.74, 18.24), were independent predictors of death. Conclusion: more than half of death occurs within 2 years. Prevalent tuberculosis, anemia, wasting, and stunting nutritional status, socioeconomic factors, and baseline opportunistic infection were independent predictors of death. Increasing early screening and managing those predictors are required.

Keywords: human immunodeficiency virus-positive children, anti-retroviral therapy, survival, treatment, Ethiopia

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Authors: Ilija Kelepurovski, Stefan Lazorovski, Pece Petkovski, Marian Anakievski, Svetlana Petkovska

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Introduction: Benign prostatic hyperplasia (BPH) is a common condition that affects men over the age of 50 and is characterized by an enlarged prostate gland that can cause lower urinary tract symptoms (LUTS). Uroflowmetry and cystoscopy are two commonly used diagnostic tests to evaluate LUTS and diagnose BPH. While both tests can be useful, there is a risk of overusing cystoscopy and underusing uroflowmetry in the evaluation of LUTS. The aim of this study was to compare the use of uroflowmetry and cystoscopy in a prospective cohort of 100 patients with suspected BPH or other urinary tract conditions and to assess the diagnostic yield of each test. Materials and Methods: This was a prospective study of 100 male patients over the age of 50 with suspected BPH or other urinary tract conditions who underwent uroflowmetry and cystoscopy for the evaluation of LUTS at a single tertiary care center. Inclusion criteria included male patients over the age of 50 with suspected BPH or other urinary tract conditions, while exclusion criteria included previous urethral or bladder surgery, active urinary tract infection, and significant comorbidities. The primary outcome of the study was the frequency of cystoscopy in the evaluation of LUTS, and the secondary outcome was the diagnostic yield of each test. Results: Of the 100 patients included in the study, 86 (86%) were diagnosed with BPH and 14 (14%) had other urinary tract conditions. The mean age of the study population was 67 years. Uroflowmetry was performed on all 100 patients, while cystoscopy was performed on 70 (70%) of the patients. The diagnostic yield of uroflowmetry was high, with a clear diagnosis made in 92 (92%) of the patients. The diagnostic yield of cystoscopy was also high, with a clear diagnosis made in 63 (90%) of the patients who underwent the procedure. There was no statistically significant difference in the diagnostic yield of uroflowmetry and cystoscopy (p = 0.20). Discussion: Our study found that uroflowmetry is an effective and well-tolerated diagnostic tool for evaluating LUTS and diagnosing BPH, with a high diagnostic yield and low risk of complications. Cystoscopy is also a useful diagnostic tool, but it is more invasive and carries a small risk of complications such as bleeding or urinary tract infection. Both tests had a high diagnostic yield, suggesting that either test can provide useful information in the evaluation of LUTS. However, the fact that 70% of the study population underwent cystoscopy raises concerns about the potential overuse of this test in the evaluation of LUTS. This is especially relevant given the focus on patient-centered care and the need to minimize unnecessary or invasive procedures. Our findings underscore the importance of considering the clinical context and using evidence-based guidelines. Conclusion: In this prospective study of 100 patients with suspected BPH or other urinary tract conditions, we found that uroflowmetry and cystoscopy were both valuable diagnostic tools for the evaluation of LUTS. However, the potential overuse of cystoscopy in this population warrants further investigation and highlights the need for careful consideration of the optimal use of diagnostic tests in the evaluation of LUTS and the diagnosis of BPH. Further research is needed to better understand the relative roles of uroflowmetry and cystoscopy in the diagnostic workup of patients with LUTS, and to develop evidence-based guidelines for their appropriate use.

Keywords: uroflowmetry, cystoscopy, LUTS, BPH

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Authors: Mohammad Didar Hossain

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Background/Purpose: The purpose of this study was to examine the associations between productive engagements and the psychological well-being of older adults in the U.S by analyzing cross-sectional data from a secondary dataset. Specifically, this paper analyzed the associations of 4 different types of productive engagements, including current work status, caregiving to the family members, volunteering and religious strengths with the psychological well-being as an outcome variable. Methods: Data and sample: The study used the data from the Health and Retirement Study (HRS). The HRS is a nationally representative prospective longitudinal cohort study that has been conducting biennial surveys since 1992 to community-dwelling individuals 50 years of age or older on diverse issues. This analysis was based on the 2016 wave (cross-sectional) of the HRS dataset and the data collection period was April 2016 through August 2017. The samples were recruited from a multistage, national area-clustered probability sampling frame. Measures: Four different variables were considered as the predicting variables in this analysis. Firstly, current working status was a binary variable that measured by 0=Yes and 1= No. The second and third variables were respectively caregiving and volunteering, and both of them were measured by; 0=Regularly, 1= Irregularly. Finally, find in strength was measured by 0= Agree and 1= Disagree. Outcome (Wellbeing) variable was measured by 0= High level of well-being, 1= Low level of well-being. Control variables including age were measured in years, education in the categories of 0=Low level of education, 1= Higher level of education and sex r in the categories 0=male, 1= female. Analysis and Results: Besides the descriptive statistics, binary logistic regression analyses were applied to examine the association between independent and dependent variables. The results showed that among the four independent variables, three of them including working status (OR: .392, p<.001), volunteering (OR: .471, p<.003) and strengths in religion (OR .588, p<.003), were significantly associated with psychological well-being while controlling for age, gender and education factors. Also, no significant association was found between the caregiving engagement of older adults and their psychological well-being outcome. Conclusions and Implications: The findings of this study are mostly consistent with the previous studies except for the caregiving engagements and their impact on older adults’ well-being outcomes. Therefore, the findings support the proactive initiatives from different micro to macro levels to facilitate opportunities for productive engagements for the older adults, and all of these may ultimately benefit their psychological well-being and life satisfaction in later life.

Keywords: productive engagements, older adults, psychological wellbeing, productive aging

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Authors: Ahmed Atwa, Ashraf Hafez, Mohamed Abdelhameed, Adel Nabeeh, Mohamed Dawaba, Tamer Helmy

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Introduction and Objective: Tumour staging and grading do not usually reflect the future behavior of Wilms' tumor (WT) regarding mortality. Therefore, in this study, P53, Ki67 and cyclin A immunohistochemistry were used in a trial to predict WT cancer-specific survival (CSS). Methods: In this nonconcurrent cohort study, patients' archived data, including age at presentation, gender, history, clinical examination and radiological investigations, were retrieved then the patients were reviewed at the outpatient clinic of a tertiary care center by history-taking, clinical examination and radiological investigations to detect the oncological outcome. Cases that received preoperative chemotherapy or died due to causes other than WT were excluded. Formalin-fixed, paraffin-embedded specimens obtained from the previously preserved blocks at the pathology laboratory were taken on positively charged slides for IHC with p53, Ki67 and cyclin A. All specimens were examined by an experienced histopathologist devoted to the urological practice and blinded to the patient's clinical findings. P53 and cyclin A staining were scored as 0 (no nuclear staining),1 (<10% nuclear staining), 2 (10-50% nuclear staining) and 3 (>50% nuclear staining). Ki67 proliferation index (PI) was graded as low, borderline and high. Results: Of the 75 cases, 40 (53.3%) were males and 35 (46.7%) were females, and the median age was 36 months (2-216). With a mean follow-up of 78.6±31 months, cancer-specific mortality (CSM) occurred in 15 (20%) and 11 (14.7%) patients, respectively. Kaplan-Meier curve was used for survival analysis, and groups were compared using the Log-rank test. Multivariate logistic regression and Cox regression were not used because only one variable (cyclin A) had shown statistical significance (P=.02), whereas the other significant factor (residual tumor) had few cases. Conclusions: Cyclin A IHC should be considered as a marker for the prediction of WT CSS. Prospective studies with a larger sample size are needed.

Keywords: wilms’ tumour, nephroblastoma, urology, survival

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Authors: Susan Lubbers

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This study applies critical discourse analysis to the language used by educators to frame international students of Asian backgrounds in Anglo-Western universities as quiet, shy, passive and unable to think critically. Emphasis is on the self-promoted ‘internationalised’ Australian tertiary context, where negative stereotypes are commonly voiced not only in the academy but also in the media. Parallels are drawn as well with other Anglo-Western educational contexts. The study critically compares the discourse of these persistent negative stereotypes, with in-class and interview discourses of international students of Asian and Western language, cultural and educational backgrounds enrolled in a Media and Popular Culture unit in an Australian university. The focus of analysis of the student discourse is on their engagement in critical dialogic interactions on the topics of culture and interculturality. The evidence is also drawn from student interviews and focus groups and from observation of whole-class discussion participation rates. The findings of the research project provide evidence that counters the myth of student as problem. They point rather to the widespread lack of intercultural awareness of Western educators and students as being at the heart of the negative perceptions of students of Asian backgrounds. The study suggests the efficacy of an approach to developing intercultural competence that is embedded, or integrated, into tertiary programs. The presentation includes an overview of the main strategies that have been developed by the tertiary educator (author) to support the development of intercultural competence of and among the student cohort. The evidence points to the importance of developing intercultural competence among tertiary educators and students. The failure by educators to ensure that the diverse voices, ideas and perspectives of students from all cultural, educational and language backgrounds are heard in our classrooms means that our universities can hardly be regarded or promoted as genuinely internationalised. They will continue as undemocratic institutions that perpetrate persistent Western educational hegemony.

Keywords: critical discourse analysis, critical thinking, embedding, intercultural competence, interculturality, international student, internationalised education

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