Search results for: recurrent aphthous stomatitis

Authors: Mariam Begadze

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Separation of Powers (SOP) has often been the most frequently posed objection against the judicial enforcement of socio-economic rights. Although a lot has been written to refute those, very rarely has it been assessed what effect the current practice of social rights adjudication has had on the construction of SOP doctrine in specific jurisdictions. Colombia is an appropriate case-study on this question. The notion of collaborative SOP in the 1991 Constitution has affected the court’s conception of its role. On the other hand, the trends in the jurisprudence have further shaped the collaborative notion of SOP. Other institutional characteristics of the Colombian constitutional law have played its share role as well. Tutela action, particularly flexible and fast judicial action for individuals has placed the judiciary in a more confrontational relation vis-à-vis the political branches. Later interventions through abstract review of austerity measures further contributed to that development. Logically, the court’s activism in this sphere has attracted attacks from political branches, which have turned out to be unsuccessful precisely due to court’s outreach to the middle-class, whose direct reliance on the court has turned into its direct democratic legitimacy. Only later have the structural judgments attempted to revive the collaborative notion behind SOP doctrine. However, the court-supervised monitoring process of implementation has itself manifested fluctuations in the mode of collaboration, moving into more managerial supervision recently. This is not surprising considering the highly dysfunctional political system in Colombia, where distrust seems to be the default starting point in the interaction of the branches. The paper aims to answer the question, what the appropriate judicial tools are to realize the collaborative notion of SOP in a context where the court has to strike a balance between the strong executive and the weak and largely dysfunctional legislative branch. If the recurrent abuse lies in the indifference and inaction of legislative branches to engage with political issues seriously, what are the tools in the court’s hands to activate the political process? The answer to this question partly lies in the court’s other strand of jurisprudence, in which it combines substantive objections with procedural ones concerning the operation of the legislative branch. The primary example is the decision on value-added tax on basic goods, in which the court invalidated the law based on the absence of sufficient deliberation in Congress on the question of the bills’ implications on the equity and progressiveness of the entire taxing system. The decision led to Congressional rejection of an identical bill based on the arguments put forward by the court. The case perhaps is the best illustration of the collaborative notion of SOP, in which the court refrains from categorical pronouncements, while does its bit for activating political process. This also legitimizes the court’s activism based on its role to counter the most perilous abuse in the Colombian context – failure of the political system to seriously engage with serious political questions.

Keywords: Colombian constitutional court, judicial review, separation of powers, social rights

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Authors: Aarti M. Shetty, Estela Davoodi, Subrata Gangooly, Anita Rao-Coppisetty

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Background: Testing Patency of Fallopian Tubes is among one of the several protocols for investigating Subfertile Couples. Both, Hysterosalpingogram (HSG) and Laparoscopy and dye test have been used as Tubal patency test for several years, with well-known limitation. Hysterosalpingo Contrast Sonography (HyCoSy) can be used as an alternative tool to HSG, to screen patency of Fallopian tubes, with an advantage of being non-ionising, and also, use of transvaginal scan to diagnose pelvic pathology. Aim: To determine the indication and analyse the performance of transvaginal scan and HyCoSy in Broomfield Hospital. Methods: We retrospectively analysed fertility workup of 282 women, who attended HyCoSy clinic at our institution from January 2015 to June 2016. An Audit proforma was designed, to aid data collection. Data was collected from patient notes and electronic records, which included patient demographics; age, parity, type of subfertility (primary or secondary), duration of subfertility, past medical history and base line investigation (hormone profile and semen analysis). Findings of the transvaginal scan, HyCoSy and Laparoscopy were also noted. Results: The most common indication for referral were as a part of primary fertility workup on couples who had failure to conceive despite intercourse for a year, other indication for referral were recurrent miscarriage, history of ectopic pregnancy, post reversal of sterilization(vasectomy and tuboplasty), Post Gynaecology surgery(Loop excision, cone biopsy) and amenorrhea. Basic Fertility workup showed 34% men had abnormal semen analysis. HyCoSy was successfully completed in 270 (95%) women using ExEm foam and Transvaginal Scan. Of the 270 patients, 535 tubes were examined in total. 495/535 (93%) tubes were reported as patent, 40/535 (7.5%) tubes were reported as blocked. A total of 17 (6.3%) patients required laparoscopy and dye test after HyCoSy. In these 17 patients, 32 tubes were examined under laparoscopy, and 21 tubes had findings similar to HyCoSy, with a concordance rate of 65%. In addition to this, 41 patients had some form of pelvic pathology (endometrial polyp, fibroid, cervical polyp, fibroid, bicornuate uterus) detected during transvaginal scan, who referred to corrective surgeries after attending HyCoSy Clinic. Conclusion: Our audit shows that HyCoSy and Transvaginal scan can be a reliable screening test for low risk women. Furthermore, it has competitive diagnostic accuracy to HSG in identifying tubal patency, with an additional advantage of screening for pelvic pathology. With addition of 3D Scan, pulse Doppler and other non-invasive imaging modality, HyCoSy may potentially replace Laparoscopy and chromopertubation in near future.

Keywords: hysterosalpingo contrast sonography (HyCoSy), transvaginal scan, tubal infertility, tubal patency test

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Authors: Amruta D. S. Pathare, Indira Hinduja, Kusum Zaveri

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Implantation failure (IF) even after the good-quality embryo transfer (ET) in the physiologically normal endometrium is the main obstacle in in vitro fertilization (IVF). Various microarray studies have been performed worldwide to elucidate the genes requisite for endometrial receptivity. These studies have included the population based on different phases of menstrual cycle during natural cycle and stimulated cycle in normal fertile women. Additionally, the literature is also available in recurrent implantation failure patients versus oocyte donors in natural cycle. However, for the first time, we aim to study the genomics of endometrial receptivity in IF patients under controlled ovarian stimulation (COS) during which ET is generally practised in IVF. Endometrial gene expression profiling in IF patients (n=10) and oocyte donors (n=8) were compared during window of implantation under COS by whole genome microarray (using Illumina platform). Enrichment analysis of microarray data was performed to determine dys-regulated biological functions and pathways using Database for Annotation, Visualization and Integrated Discovery, v6.8 (DAVID). The enrichment mapping was performed with the help of Cytoscape software. Microarray results were validated by real-time PCR. Localization of genes related to immune response (Progestagen-Associated Endometrial Protein (PAEP), Leukaemia Inhibitory Factor (LIF), Interleukin-6 Signal Transducer (IL6ST) was detected by immunohistochemistry. The study revealed 418 genes downregulated and 519 genes upregulated in IF patients compared to healthy fertile controls. The gene ontology, pathway analysis and enrichment mapping revealed significant downregulation in activation and regulation of immune and inflammation response in IF patients under COS. The lower expression of Progestagen Associated Endometrial Protein (PAEP), Leukemia Inhibitory Factor (LIF) and Interleukin 6 Signal Transducer (IL6ST) in cases compared to controls by real time and immunohistochemistry suggests the functional importance of these genes. The study was proved useful to uncover the probable reason of implantation failure being imbalance of immune and inflammatory regulation in our group of subjects. Based on the present study findings, a panel of significant dysregulated genes related to immune and inflammatory pathways needs to be further substantiated in larger cohort in natural as well as stimulated cycle. Upon which these genes could be screened in IF patients during window of implantation (WOI) before going for embryo transfer or any other immunological treatment. This would help to estimate the regulation of specific immune response during WOI in a patient. The appropriate treatment of either activation of immune response or suppression of immune response can be then attempted in IF patients to enhance the receptivity of endometrium.

Keywords: endometrial receptivity, immune and inflammatory response, gene expression microarray, window of implantation

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Authors: Aoxue Yang, Weili Tian, Haikun Liu

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Brain tumor stem cells (BTSCs) are resistant to therapy and give rise to recurrent tumors. These rare and elusive cells are likely to disseminate during cancer progression, and some may enter dormancy, remaining viable but not increasing. The identification of dormant BTSCs is thus necessary to design effective therapies for glioblastoma (GBM) patients. Glucocorticoids (GCs) are used to treat GBM-associated edema. However, glucocorticoids participate in the physiological response to psychosocial stress, linked to poor cancer prognosis. This raises concern that glucocorticoids affect the tumor and BTSCs. Identifying markers specifically expressed by brain tumor stem cells (BTSCs) may enable specific therapies that spare their regular tissue-resident counterparts. By ribosome profiling analysis, we have identified that glycerol-3-phosphate dehydrogenase 1 (GPD1) is expressed by dormant BTSCs but not by NSCs. Through different stress-induced experiments in vitro, we found that only dexamethasone (DEXA) can significantly increase the expression of GPD1 in NSCs. Adversely, mifepristone (MIFE) which is classified as glucocorticoid receptors antagonists, could decrease GPD1 protein level and weaken the proliferation and stemness in BTSCs. Furthermore, DEXA can induce GPD1 expression in tumor-bearing mice brains and shorten animal survival, whereas MIFE has a distinct adverse effect that prolonged mice lifespan. Knocking out GR in NSC can block the upregulation of GPD1 inducing by DEXA, and we find the specific sequences on GPD1 promotor combined with GR, thus improving the efficiency of GPD1 transcription from CHIP-Seq. Moreover, GR and GPD1 are highly co-stained on GBM sections obtained from patients and mice. All these findings confirmed that GR could regulate GPD1 and loss of GPD1 Impairs Multiple Pathways Important for BTSCs Maintenance GPD1 is also a critical enzyme regulating glycolysis and lipid synthesis. We observed that DEXA and MIFE could change the metabolic profiles of BTSCs by regulating GPD1 to shift the transition of cell dormancy. Our transcriptome and lipidomics analysis demonstrated that cell cycle signaling and phosphoglycerides synthesis pathways contributed a lot to the inhibition of GPD1 caused by MIFE. In conclusion, our findings raise concern that treatment of GBM with GCs may compromise the efficacy of chemotherapy and contribute to BTSC dormancy. Inhibition of GR can dramatically reduce GPD1 and extend the survival duration of GBM-bearing mice. The molecular link between GPD1 and GR may give us an attractive therapeutic target for glioblastoma.

Keywords: cancer stem cell, dormancy, glioblastoma, glycerol-3-phosphate dehydrogenase 1, glucocorticoid receptor, dexamethasone, RNA-sequencing, phosphoglycerides

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Authors: Jemma McGourty, Brid Delahunt, Fiona Hackett, Sharon Courtney, Richard English, Graham Russell, Sinéad O’Connor

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Fundamental Movement Skills (FMS) mastery is considered essential for children’s ongoing, meaningful engagement in Physical Activity (PA). There has been a dearth of Irish research on baseline FMS and their development by means of intervention in young primary school children. In addition, as children’s participation in PA is heavily influenced by both parents and teachers, it is imperative to understand their attitudes and perceptions towards PA participation and its’ promotion in children. The ‘Fun, Move, Play’ Project investigated the effect of a 6-week play based PA intervention on primary school children’s (aged 6-8 years) FMS while also exploring the attitudes and perceptions of their parents and teachers towards PA participation. The FMS intervention utilised a pre-post quasi-experimental design to determine the effect of a 6-week play based PA intervention (devised from the iCoach Kids Programme) on 176 primary school children’s FMS (N = 176: 90 girls and 86 boys; M = 7.2 years; SD = 0.48). Objective measures of 7 FMS (run, skip, vertical jump, static balance, stationary dribble, catch, kick) were made using a combination of the TGMD2 and Get Skilled, Get Active resources. One hundred parents (87 mothers; 13 fathers; M=36 years; SD=5.45) and 90 teachers (67 females; 23 males) completed surveys investigating their attitudes and perceptions towards PA participation. In addition, 19 of these parents and 9 of these teachers participated in semi-structured qualitative interviews to explore, in more depth, their views and perceptions of PA participation. Both the FMS data set and survey responses were analysed using SPSS version 23, using appropriate statistical analysis. A thematic analysis framework was used to analyse the qualitative findings. A significant improvement was observed in the children’s overall FMS score pre-post intervention (t = 16.67; df = 175; p < 0.001), while there were also significant improvements in each of the seven individual FMS measured in the children, pre-post intervention. Findings from the parent surveys and interviews indicated that parents had positive attitudes towards PA, viewed it as important and supported their child’s PA participation. However, a lack of knowledge regarding the amount and intensity of PA that children should participate in emerged as a recurrent finding. Also, there was a significant positive correlation between the PA levels of parents’ and their children (r = .41; n = 100; p < .001). Arising from the teachers’ surveys and interviews was a positive attitude towards PA and the impact that it has on a child’s health and well-being. They also reported feeling more confident teaching certain aspects of the PE curriculum (games and sports) compared to others (gymnastics, dance), where they appreciate working with specialist practitioners. Conclusion: A short-term PA intervention has a positive effect on children’s FMS. While parents are supportive of their child’s PA participation, there is a knowledge gap regarding National PA guidelines for children. Teachers appreciate the importance of PA in children, but face a number of challenges in its implementation and promotion.

Keywords: fundamental movement skills, parents attitudes to physical activity, short-term intervention, teachers attitudes to physical activity

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Authors: Marina Shargorodsky

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Aim: Gestational weight gain (GWG) has been related to altering future weight-gain curves and increased risks of obesity later in life. Obesity may contribute to vascular atherosclerotic changes as well as excess cardiovascular morbidity and mortality observed in these patients. Noninvasive arterial testing, such as ultrasonographic measurement of carotid IMT, is considered a surrogate for systemic atherosclerotic disease burden and is predictive of cardiovascular events in asymptomatic individuals as well as recurrent events in patients with known cardiovascular disease. Currently, there is no consistent evidence regarding the vascular impact of excessive GWG. The present study was designed to investigate the impact of GWG on early atherosclerotic changes during late pregnancy, using intima-media thickness, as well as placental vascular circulation and inflammatory lesions and pregnancy outcomes. Methods: The study group consisted of 59 pregnant women who gave birth and underwent a placental histopathological examination at the Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Israel, in 2019. According to the IOM guidelines the study group has been divided into two groups: Group 1 included 32 women with pregnancy weight gain within recommended range; Group 2 included 27 women with excessive weight gain during pregnancy. The IMT was measured from non-diseased intimal and medial wall layers of the carotid artery on both sides, visualized by high-resolution 7.5 MHz ultrasound (Apogee CX Color, ATL). Placental histology subdivided placental findings to lesions consistent with maternal vascular and fetal vascular malperfusion according to the criteria of the Society for Pediatric Pathology, subdividing placental findings to lesions consistent with maternal vascular and fetal vascular malperfusion, as well as the inflammatory response of maternal and fetal origin. Results: IMT levels differed between groups and were significantly higher in Group 1 compared to Group 2 (0.7+/-0.1 vs 0.6+/-0/1, p=0.028). Multiple linear regression analysis of IMT included variables based on their associations in univariate analyses with a backward approach. Included in the model were pre-gestational BMI, HDL cholesterol and fasting glucose. The model was significant (p=0.001) and correctly classified 64.7% of study patients. In this model, pre-pregnancy BMI remained a significant independent predictor of subclinical atherosclerosis assessed by IMT (OR 4.314, 95% CI 0.0599-0.674, p=0.044). Among placental lesions related to fetal vascular malperfusion, villous changes consistent with fetal thrombo-occlusive disease (FTOD) were significantly higher in Group 1 than in Group 2, p=0.034). In Conclusion, the present study demonstrated that excessive weight gain during pregnancy is associated with an adverse effect on early stages of subclinical atherosclerosis, placental vascular circulation and neonatal complications. The precise mechanism for these vascular changes, as well as the overall clinical impact of weight control during pregnancy on IMT, placental vascular circulation as well as pregnancy outcomes, deserves further investigation.

Keywords: obesity, pregnancy, complications, weight gain

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Authors: A. Askerov, Y. Teterin, P. Yartcev, S. Novikov

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Introduction: Acute pancreatitis (AP) is a socially significant problem for public health and continues to be one of the most common causes of hospitalization of patients with pathology of the gastrointestinal tract. It is characterized by high mortality rates, which reaches 62-65% in infected pancreatic necrosis. Aims & Methods: The study group included 63 patients who underwent transluminal drainage (TLD) fluid collection (FC). All patients were performed transabdominal ultrasound, computer tomography of the abdominal cavity and retroperitoneal organs and endoscopic ultrasound (EUS) of the pancreatobiliary zone. The EUS was used as a final diagnostic method to determine the characteristics of FC. The indications for TLD were: the distance between the wall of the hollow organ and the FC was not more than 1 cm, the absence of large vessels on the puncture trajectory (more than 3 mm), and the size of the formation was more than 5 cm. When a homogeneous cavity with clear, even contours was detected, a plastic stent with rounded ends (“double pig tail”) was installed. The indication for the installation of a fully covered self-expanding stent was the detection of nonhomogeneous anechoic FC with hyperechoic inclusions and cloudy purulent contents. In patients with necrotic forms after drainage of the purulent cavity, a cystonasal drainage with a diameter of 7Fr was installed in its lumen under X-ray control to sanitize the cavity with a 0.05% aqueous solution of chlorhexidine. Endoscopic necrectomy was performed every 24-48 hours. The plastic stent was removed in 6 month, the fully covered self-expanding stent - in 1 month after the patient was discharged from the hospital. Results: Endoscopic TLD was performed in 63 patients. The FC corresponding to interstitial edematous pancreatitis was detected in 39 (62%) patients who underwent TLD with the installation of a plastic stent with rounded ends. In 24 (38%) patients with necrotic forms of FC, a fully covered self-expanding stent was placed. Communication with the ductal system of the pancreas was found in 5 (7.9%) patients. They underwent pancreaticoduodenal stenting. A complicated postoperative period was noted in 4 (6.3%) cases and was manifested by bleeding from the zone of pancreatogenic destruction. In 2 (3.1%) cases, this required angiography and endovascular embolization a. gastroduodenalis, in 1 (1.6%) case, endoscopic hemostasis was performed by filling the cavity with 4 ml of Hemoblock hemostatic solution. The combination of both methods was used in 1 (1.6%) patient. There was no evidence of recurrent bleeding in these patients. Lethal outcome occurred in 4 patients (6.3%). In 3 (4.7%) patients, the cause of death was multiple organ failure, in 1 (1.6%) - severe nosocomial pneumonia that developed on the 32nd day after drainage. Conclusions: 1. EUS is not only the most important method for diagnosing FC in AP, but also allows you to determine further tactics for their intraluminal drainage.2. Endoscopic intraluminal drainage of fluid zones in 45.8% of cases is the final minimally invasive method of surgical treatment of large-focal pancreatic necrosis. Disclosure: Nothing to disclose.

Keywords: acute pancreatitis, fluid collection, endoscopy surgery, necrectomy, transluminal drainage

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Authors: Beverly Wang

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Background: Rosai-Dorfman disease (RDD), aka sinus histiocytosis with massive lymphadenopathy, is a rare, idiopathic histiocytic proliferative disorder. Although RDD can be seen involving the head and neck lymph nodes, rarely it can affect other extranodal sites. It present 3 unique cases of RDD affecting the nasal cavity, paranasal sinuses, and ear canal. The initial clinical presentation on two cases mimicked a malignant neoplasm. The 3rd case of RDD co-existed with a cholesteatoma of the ear canal. The clinical presentation, histology and immunohistochemical stains, and radiographic findings are discussed. Design: An overview of 3 cases of RDD affected sinonasal cavity and ear canal from UCI Medical Center was conducted. Case 1: A 61 year old male complaining of breathing difficulty presented with bilateral polypoid sinonasal masses and severe nasal obstruction. The masses elevated the nasal floor, and involved the anterior nasal septum to lateral wall. It was endoscopically excised. At intraoperative consultation, frozen section reported a pleomorphic spindle cell neoplasm with scattered large atypical spindle cells, resembling a high grade sarcoma. Case 2: A 46 year old male presented with recurrent bilateral maxillary chronic sinusitis with mass formation, clinically suspicious for malignant lymphoma. Excisional tissue sample showed large irregular spindled histiocytes with abundant granular and vacuolated cytoplasm. Case 3: A 36 year old female with a history of asthma initially presented with left-sided chronic otalgia, occasional nausea, vertigo, and fluctuating pain exacerbated by head movement and temperature changes. CT scan revealed an external auditory canal mass extending to the middle ear, coexisting with a small cholesteatoma. Results: The morphology of all cases revealed large atypical spindled histiocytes resembling fibrohistiocytic or myofibroblastic proliferative neoplasms. Scattered emperipolesis was seen. All 3 cases were confirmed as extranodal sinus RDD, confirmed by immunohistochemistry. The large atypical cells were positive for S100, CD68, and CD163. No evidence for malignancy was identified. Case 3 showed concurrent RDD co-existing with a cholesteatoma. Conclusion: Due to its rarity and variable clinical presentations, the diagnosis of RDD is seldom clinically considered. Extranodal sinus RDD morphologically can be pitfall as mimicker of spindly neoplasm, especially at intraoperative consultation. It can create diagnostic and therapeutic challenges. Correlation of radiological findings with histologic features will help to reach the diagnosis.

Keywords: head and neck, extranodal, rosai-dorfman disease, mimicker, immunohistochemistry

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Authors: Kostas Kouvaris, Anastasia Eleftheriou, Georgios A. Sarantitis, Apostolos Chondronasios

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To achieve the objective of almost zero carbon energy solutions by 2050, the EU needs to accelerate the development of integrated, highly efficient and environmentally friendly solutions. In this direction, district heating and cooling (DHC) emerges as a viable and more efficient alternative to conventional, decentralized heating and cooling systems, enabling a combination of more efficient renewable and competitive energy supplies. In this paper, we develop a forecasting tool for near real-time local weather and thermal energy demand predictions for an entire DHC network. In this fashion, we are able to extend the functionality and to improve the energy efficiency of the DHC network by predicting and adjusting the heat load that is distributed from the heat generation plant to the connected buildings by the heat pipe network. Two case-studies are considered; one for Vransko, Slovenia and one for Montpellier, France. The data consists of i) local weather data, such as humidity, temperature, and precipitation, ii) weather forecast data, such as the outdoor temperature and iii) DHC operational parameters, such as the mass flow rate, supply and return temperature. The external temperature is found to be the most important energy-related variable for space conditioning, and thus it is used as an external parameter for the energy demand models. For the development of the forecasting tool, we use state-of-the-art deep neural networks and more specifically, recurrent networks with long-short-term memory cells, which are able to capture complex non-linear relations among temporal variables. Firstly, we develop models to forecast outdoor temperatures for the next 24 hours using local weather data for each case-study. Subsequently, we develop models to forecast thermal demand for the same period, taking under consideration past energy demand values as well as the predicted temperature values from the weather forecasting models. The contributions to the scientific and industrial community are three-fold, and the empirical results are highly encouraging. First, we are able to predict future thermal demand levels for the two locations under consideration with minimal errors. Second, we examine the impact of the outdoor temperature on the predictive ability of the models and how the accuracy of the energy demand forecasts decreases with the forecast horizon. Third, we extend the relevant literature with a new dataset of thermal demand and examine the performance and applicability of machine learning techniques to solve real-world problems. Overall, the solution proposed in this paper is in accordance with EU targets, providing an automated smart energy management system, decreasing human errors and reducing excessive energy production.

Keywords: machine learning, LSTMs, district heating and cooling system, thermal demand

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Authors: Jean-Philippe Amat, Timothée Vergne, Aymeric Hans, Bénédicte Ferry, Pascal Hendrikx, Jackie Tapprest, Barbara Dufour, Agnès Leblond

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The surveillance of infectious diseases is necessary to describe their occurrence and help the planning, implementation and evaluation of risk mitigation activities. However, the exact number of detected cases may remain unknown whether surveillance is based on serological tests because identifying seroconversion may be difficult. Moreover, incomplete detection of cases or outbreaks is a recurrent issue in the field of disease surveillance. This study addresses these two issues. Using a viral animal disease as an example (equine viral arteritis), the goals were to establish suitable rules for identifying seroconversion in order to estimate the number of cases and outbreaks detected by a surveillance system in France between 2006 and 2013, and to assess the sensitivity of this system by estimating the total number of outbreaks that occurred during this period (including unreported outbreaks) using a capture-recapture model. Data from horses which exhibited at least one positive result in serology using viral neutralization test between 2006 and 2013 were used for analysis (n=1,645). Data consisted of the annual antibody titers and the location of the subjects (towns). A consensus among multidisciplinary experts (specialists in the disease and its laboratory diagnosis, epidemiologists) was reached to consider seroconversion as a change in antibody titer from negative to at least 32 or as a three-fold or greater increase. The number of seroconversions was counted for each town and modeled using a unilist zero-truncated binomial (ZTB) capture-recapture model with R software. The binomial denominator was the number of horses tested in each infected town. Using the defined rules, 239 cases located in 177 towns (outbreaks) were identified from 2006 to 2013. Subsequently, the sensitivity of the surveillance system was estimated as the ratio of the number of detected outbreaks to the total number of outbreaks that occurred (including unreported outbreaks) estimated using the ZTB model. The total number of outbreaks was estimated at 215 (95% credible interval CrI95%: 195-249) and the surveillance sensitivity at 82% (CrI95%: 71-91). The rules proposed for identifying seroconversion may serve future research. Such rules, adjusted to the local environment, could conceivably be applied in other countries with surveillance programs dedicated to this disease. More generally, defining ad hoc algorithms for interpreting the antibody titer could be useful regarding other human and animal diseases and zoonosis when there is a lack of accurate information in the literature about the serological response in naturally infected subjects. This study shows how capture-recapture methods may help to estimate the sensitivity of an imperfect surveillance system and to valorize surveillance data. The sensitivity of the surveillance system of equine viral arteritis is relatively high and supports its relevance to prevent the disease spreading.

Keywords: Bayesian inference, capture-recapture, epidemiology, equine viral arteritis, infectious disease, seroconversion, surveillance

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Authors: Maria L. McLeod

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This study examines the ways in which cancer patient narratives are portrayed and framed on the websites of three leading U.S. cancer care centers –The University of Texas MD Anderson Cancer Center in Houston, Memorial Sloan Kettering Cancer Center in New York, and Seattle Cancer Care Alliance. Thirty patient stories, ten from each cancer center website blog, were analyzed using qualitative and quantitative textual analysis of unstructured data, documenting repeated use of specific metaphors and tropes while charting common themes and other elements of story structure and content. Patient narratives were coded using grounded theory as the basis for conducting emergent qualitative research. As part of a systematic, inductive approach to collecting and analyzing data, recurrent and unique themes were examined and compared in terms of positive and negative framing, patient agency, and institutional praise. All three of these cancer care centers are teaching hospitals with university affiliations, that emphasizes an evidence-based scientific approach to treatment that utilizes the latest research and cutting-edge techniques and technology. Thus, the use of anecdotal evidence presented in patient narratives could be perceived as being in conflict with this evidence-based model, as the patient stories are not an accurate representation of scientific outcomes related to developing cancer, cancer reoccurrence, or cancer outcomes. The representative patient narratives tend to exclude or downplay adverse responses to treatment, survival rates, integrative and/or complementary cancer treatments, cancer prevention and causes, and barriers to treatment, such as the limitation of insurance plans, costs of treatment, and/or other issues related to access, potentially contributing to false narratives and inaccurate notions of cancer prevention, cancer care treatment and the potential for a cure. Both quantitative and qualitative findings demonstrate that cancer patient stories featured on the blogsites of the nation’s top cancer care centers deemphasize patient agency and, instead, emphasize deference and gratitude toward the institutions where the featured patients received treatment. Along these lines, language choices reflect positive framing of the cancer experience. Accompanying portrait photos of healthy appearing subjects as well as positive-framed headlines, subheads, and pull quotes function similarly, reflecting hopeful, transformative experiences and outcomes over hardship and suffering. Although patient narratives include real, factual scientific details and descriptions of actual events, the stories lack references to more negative realities of cancer diagnosis and treatment. Instead, they emphasize the triumph of survival by which the cancer care center, in the savior/hero role, enables the patient’s success, represented as a cathartic medical journey.

Keywords: cancer framing, cancer stories, medical gaze, patient narratives

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Authors: Purushottam P. Khatiwada, Bikash Paudel, Ram B. Rana, Parshuram Biswakarma, Roshan Pudasaini

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Nepal has been putting its efforts into securing food and nutrition security for its citizens adopting different models and approaches. Home Garden approach, that integrates vegetables, fruits, small livestock, poultry along with other components like fish, honeybee, mushroom, spices for the promotion of nutritional security of resource-poor and disadvantaged groups was implemented during March 2009 to July 2013 spreading over 16 districts of Nepal covering 115 farmers groups, directly working with 3500 households. Sustained long-term impact of development interventions targeted to the resource-poor and disadvantaged groups has been a recurrent issue for donors, policymakers and practitioners alike. Considering the issue, a post-project evaluation was carried out in a selected project group (Dangibari of Jhapa) after four years of project completion in 2017 in order to evaluate the impact and understand the factors associated with its success. Qualitative information was collected through focus group discussion with group members and associated local institutions. For quantitative information, a quick survey was carried out to the same group members only selecting few indicators. The results are compared with the data obtained from the baseline study conducted by the project in March 2009. The impact of project intervention was evident as compared to the benchmarks established during the baseline, even after four years of project completion. The area under home garden is increased to 729 m² from 386 m² and average food self-sufficiency months increased to 10.22 from 8.11. Seven to eleven fruit species are maintained in the home gardens. An average number of vegetable species grown increased to 15.85 from 9.86. It has resulted in an increase in vegetables self-sufficient month to 8.74 from 4.74 and a huge increase in cash income NPR 6142.8 (USD 59.6) from NPR 385.7 (USD 3.9) from the sale of surplus vegetables. Coaching and mentoring including nutrition sensitization by the project staff at the beginning, inputs and technical support during the project implementation phase and projects effort on the institutional building of disadvantaged farmers were the key drivers of home garden sustainability and expansion. Specifically, package of home garden management trainings provided by the project staff, availability of group funds for buying inputs even after the project, uniting home garden group members in a cooperative, resource leveraging by local institutions through group lobbying, farmers innovations for maintaining home garden diversity and continuous backstopping support by few active members as local resource persons to other members are some additional factors contributing to sustain and/or improve the home garden status by the resource-poor and disadvantaged group.

Keywords: food-based nutrition, home garden, resource-poor and disadvantaged group, sustained impact

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Authors: Catherine Constantinidis (Nee Tsacalos)

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This paper presents one aspect of the larger Masters qualitative study exploring the roles of married Greek Orthodox clergy, the Priest and Presbytera, under the wing of the Greek Orthodox Archdiocese of Australia. This ground breaking research necessitated the creation of primary data within a phenomenological paradigm drawing from lived experiences of the Priests and Presbyteres in contemporary society. As a Social Worker, a bilingual (Greek/English) Mental Health practitioner and a Presbytera, the questions constantly raised and pondered are: Who do the Priest and Presbytera turn to when they experience difficulties or problems? Where do they go for support? What is in place for their emotional and psychological health and well-being? Who cares for the spiritual carer? Who is there to catch our falling clergy and their wives? What is their 'safety net'? Identified phenomena of angst, stress, frustration and confusion experienced by the Priest and (by extension) the Presbytera, within their position, coupled with basic assumptions, perceptions and expectations about their roles, the role of the organisation (the Church), and their role as spouse often caused confusion and in some cases conflict. Unpacking this complex and multi-dimensional relationship highlighted not only the roller coaster of emotions, potentially affecting their physical and mental health, but also the impact on the interwoven relationships of marriage and ministry. The author considers these phenomena in the light of bilingual cultural and religious organisational practice frameworks, specifically the Greek Orthodox Church, whilst filtering these findings through a mental health lens. One could argue that it is an expectation that clergy (and by default their wives) take on the responsibility to be kind, nurturing and supportive to others. However, when it comes to taking care of self, they are not nearly as kind. This research looks at a recurrent theme throughout the interviews where all participants talked about limited support systems and poor self care strategies and the impact this has on their ministry, mental, emotional, and physical health and ultimately on their relationships with self and others. The struggle all participants encountered at some point in their ministry was physical, spiritual and psychological burn out. The overall aim of the researcher is to provide a voice for the Priest and the Presbytera painting a clearer picture of these roles and facilitating an awareness of struggles and dilemmas faced in their ministry. It is hoped these identified gaps in self care strategies and support systems will provide solid foundations for building a culturally sensitive, empathetic and effective support system framework, incorporating the spiritual and psychological well-being of the Priest and Presbytera, a ‘safety net’. A supplementary aim is to inform and guide ministry practice frameworks for clergy, spouses, the church hierarchy and religious organisations on a local and global platform incorporating some sort of self-care system.

Keywords: care for the carer, mental health, Priest, Presbytera, religion, support system

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Authors: Lucia Liu, Matthew Koziol

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Obsessive-compulsive disorder (OCD), a long-lasting anxiety disorder involving recurrent, intrusive thoughts, affects over 2 million adults in the United States. Transcranial magnetic stimulation (TMS) stands out as a noninvasive, cutting-edge therapy that has been shown to reduce symptoms in patients with treatment-resistant OCD. The Food and Drug Administration (FDA) approved protocol pairs TMS sessions with individualized symptom provocation, aiming to improve the susceptibility of brain circuits to stimulation. However, limited standardization or guidance exists on how to conduct symptom provocation and which methods are most effective. This study aims to compare the effect of internal versus external techniques to induce obsessional stress in a clinical setting during TMS therapy. Two symptom provocation methods, (i) Asking patients thought-provoking questions about their obsessions (internal) and (ii) Requesting patients to perform obsession-related tasks (external), were employed in a crossover design with repeated measurement. Thirty-six treatments of NeuroStar TMS were administered to each of two patients over 8 weeks in an outpatient clinic. Patient One received 18 sessions of internal provocation followed by 18 sessions of external provocation, while Patient Two received 18 sessions of external provocation followed by 18 sessions of internal provocation. The primary outcome was the level of self-reported obsessional stress on a visual analog scale from 1 to 10. The secondary outcome was self-reported OCD severity, collected biweekly in a four-level Likert-scale (1 to 4) of bad, fair, good and excellent. Outcomes were compared and tested between provocation arms through repeated measures ANOVA, accounting for intra-patient correlations. Ages were 42 for Patient One (male, White) and 57 for Patient Two (male, White). Both patients had similar moderate symptoms at baseline, as determined through the Yale-Brown Obsessive Compulsive Scale (YBOCS). When comparing obsessional stress induced across the two arms of internal and external provocation methods, the mean (SD) was 6.03 (1.18) for internal and 4.01 (1.28) for external strategies (P=0.0019); ranges were 3 to 8 for internal and 2 to 8 for external strategies. Internal provocation yielded 5 (31.25%) bad, 6 (33.33%) fair, 3 (18.75%) good, and 2 (12.5%) excellent responses for OCD status, while external provocation yielded 5 (31.25%) bad, 9 (56.25%) fair, 1 (6.25%) good, and 1 (6.25%) excellent responses (P=0.58). Internal symptom provocation tactics had a significantly stronger impact on inducing obsessional stress and led to better OCD status (non-significant). This could be attributed to the fact that answering questions may prompt patients to reflect more on their lived experiences and struggles with OCD. In the future, clinical trials with larger sample sizes are warranted to validate this finding. Results support the increased integration of internal methods into structured provocation protocols, potentially reducing the time required for provocation and achieving greater treatment response to TMS.

Keywords: obsessive-compulsive disorder, transcranial magnetic stimulation, mental health, symptom provocation

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Authors: Sunil Chandra, Himanshu Rawat, Vikas Gusain, Triparna Barman

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Forest fires are a recurrent phenomenon in the Himalayan region owing to the presence of vulnerable forest types, topographical gradients, climatic weather conditions, and anthropogenic pressure. The present study focuses on the identification of forest fire-affected areas in a small part of the West Himalayan region using a differential normalized burnt ratio method and spectral unmixing methods. The study area has a rugged terrain with the presence of sub-tropical pine forest, montane temperate forest, and sub-alpine forest and scrub. The major reason for fires in this region is anthropogenic in nature, with the practice of human-induced fires for getting fresh leaves, scaring wild animals to protect agricultural crops, grazing practices within reserved forests, and igniting fires for cooking and other reasons. The fires caused by the above reasons affect a large area on the ground, necessitating its precise estimation for further management and policy making. In the present study, two approaches have been used for carrying out a burnt area analysis. The first approach followed for burnt area analysis uses a differenced normalized burnt ratio (dNBR) index approach that uses the burnt ratio values generated using the Short-Wave Infrared (SWIR) band and Near Infrared (NIR) bands of the Sentinel-2 image. The results of the dNBR have been compared with the outputs of the spectral mixing methods. It has been found that the dNBR is able to create good results in fire-affected areas having homogenous forest stratum and with slope degree <5 degrees. However, in a rugged terrain where the landscape is largely influenced by the topographical variations, vegetation types, tree density, the results may be largely influenced by the effects of topography, complexity in tree composition, fuel load composition, and soil moisture. Hence, such variations in the factors influencing burnt area assessment may not be effectively carried out using a dNBR approach which is commonly followed for burnt area assessment over a large area. Hence, another approach that has been attempted in the present study utilizes a spectral mixing method where the individual pixel is tested before assigning an information class to it. The method uses a neural network approach utilizing Sentinel-2 bands. The training and testing data are generated from the Sentinel-2 data and the national field inventory, which is further used for generating outputs using ML tools. The analysis of the results indicates that the fire-affected regions and their severity can be better estimated using spectral unmixing methods, which have the capability to resolve the noise in the data and can classify the individual pixel to the precise burnt/unburnt class.

Keywords: categorical data, log linear modeling, neural network, shifting cultivation

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Authors: Zhao Gao, Eran Edirisinghe

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The production of an accurate sketch of a suspect based on a verbal description obtained from a witness is an essential task for most criminal investigations. The criminal investigation system employs specifically trained professional artists to manually draw a facial image of the suspect according to the descriptions of an eyewitness for subsequent identification. Within the advancement of Deep Learning, Recurrent Neural Networks (RNN) have shown great promise in Natural Language Processing (NLP) tasks. Additionally, Generative Adversarial Networks (GAN) have also proven to be very effective in image generation. In this study, a trained GAN conditioned on textual features such as keywords automatically encoded from a verbal description of a human face using an RNN is used to generate photo-realistic facial images for criminal investigations. The intention of the proposed system is to map corresponding features into text generated from verbal descriptions. With this, it becomes possible to generate many reasonably accurate alternatives to which the witness can use to hopefully identify a suspect from. This reduces subjectivity in decision making both by the eyewitness and the artist while giving an opportunity for the witness to evaluate and reconsider decisions. Furthermore, the proposed approach benefits law enforcement agencies by reducing the time taken to physically draw each potential sketch, thus increasing response times and mitigating potentially malicious human intervention. With publically available 'CelebFaces Attributes Dataset' (CelebA) and additionally providing verbal description as training data, the proposed architecture is able to effectively produce facial structures from given text. Word Embeddings are learnt by applying the RNN architecture in order to perform semantic parsing, the output of which is fed into the GAN for synthesizing photo-realistic images. Rather than the grid search method, a metaheuristic search based on genetic algorithms is applied to evolve the network with the intent of achieving optimal hyperparameters in a fraction the time of a typical brute force approach. With the exception of the ‘CelebA’ training database, further novel test cases are supplied to the network for evaluation. Witness reports detailing criminals from Interpol or other law enforcement agencies are sampled on the network. Using the descriptions provided, samples are generated and compared with the ground truth images of a criminal in order to calculate the similarities. Two factors are used for performance evaluation: The Structural Similarity Index (SSIM) and the Peak Signal-to-Noise Ratio (PSNR). A high percentile output from this performance matrix should attribute to demonstrating the accuracy, in hope of proving that the proposed approach can be an effective tool for law enforcement agencies. The proposed approach to criminal facial image generation has potential to increase the ratio of criminal cases that can be ultimately resolved using eyewitness information gathering.

Keywords: RNN, GAN, NLP, facial composition, criminal investigation

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Authors: Ali Aqa Mohammad Jawad

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Taking a relational approach, this paper analyzes the causal mechanisms associated with successful mobilization and rapid demobilization of the Enlightening Movement in post-2001 Afghanistan. The movement emerged after the state-owned Da Afghan Bereshna Sherkat (DABS) decided to divert the route for the Turkmenistan-Uzbekistan-Tajikistan-Afghanistan-Pakistan (TUTAP) electricity project. The grid was initially planned to go through the Hazara-inhabited province of Bamiyan, according to Afghanistan’s Power Sector Master Plan. The reroute served as an aide-mémoire of historical subordination to other ethno-religious groups for the Hazara community. It was also perceived as deprivation from post-2001 development projects, financed by international aid. This torched the accumulated grievances, which then gave birth to the Enlightening Movement. The movement had a successful mobilization. However, it demobilized after losing much of its mobilizing capabilities through an amalgamation of external and internal relational factors. The successful mobilization yet rapid demobilization constitutes the puzzle of this paper. From the theoretical perspective, this paper is significant as it establishes the applicability of contentious politics theory to protest mobilizations that occurred in Afghanistan, a context-specific, characterized by ethnic politics. Both primary and secondary data are utilized to address the puzzle. As for the primary resources, media coverage, interviews, reports, public media statements of the movement, involved in contentious performances, and data from Social Networking Services (SNS) are used. The covered period is from 2001-2018. As for the secondary resources, published academic articles and books are used to give a historical account of contentious politics. For data analysis, a qualitative comparative historical method is utilized to uncover the causal mechanisms associated with successful mobilization and rapid demobilization of the Movement. In this pursuit, both mobilization and demobilization are considered as larger political processes that could be decomposed to constituent mechanisms. Enlightening Movement’s framing and campaigns are first studied to uncover the associated mechanisms. Then, to avoid introducing some ad hoc mechanisms, the recurrence of mechanisms is checked against another case. Mechanisms qualify as robust if they are “recurrent” in different episodes of contention. Checking the recurrence of causal mechanisms is vital as past contentious events tend to reinforce future events. The findings of this paper suggest that the public sphere in Afghanistan is drastically different from Western democracies known as the birthplace of social movements. In Western democracies, when institutional politics did not respond, movement organizers occupied the public sphere, undermining the legitimacy of the government. In Afghanistan, the public sphere is ethicized. Considering the inter- and intra-relational dynamics of ethnic groups in Afghanistan, the movement reduced to an erosive inter- and intra-ethnic conflict. This undermined the cohesiveness of the movement, which then kicked-off its demobilization process.

Keywords: enlightening movement, contentious politics, mobilization, demobilization

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Authors: Lucile Rapin, Cynthia El Hage, Rihab Gamaoun, Maria-Fernanda Arboleda, Erin Prosk

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Introduction: Sante Cannabis (SC), a Canadian group of clinics dedicated to medical cannabis, based in Montreal and in the province of Quebec, has served more than 8000 patients seeking cannabis-based treatment over the past five years. As randomized clinical trials with natural medical cannabis are scarce, real-world evidence offers the opportunity to fill research gaps between scientific evidence and clinical practice. Data on the use of medical cannabis products from SC patients were prospectively collected, leading to a large real-world database on the use of medical cannabis. The aim of this study was to report information on the profiles of both patients and prescribed medical cannabis products at SC clinics, and to assess the safety of medical cannabis among Canadian patients. Methods: This is an observational retrospective study of 1342 adult patients who were authorized with medical cannabis products between October 2017 and September 2019. Information regarding demographic characteristics, therapeutic indications for medical cannabis use, patterns in dosing and dosage form of medical cannabis and adverse effects over one-year follow-up (initial and 4 follow-up (FUP) visits) were collected. Results: 59% of SC patients were female, with a mean age of 56.7 (SD= 15.6, range= (19-97)). Cannabis products were authorized mainly for patients with a diagnosis of chronic pain (68.8% of patients), cancer (6.7%), neurological disorders (5.6%), and mood disorders (5.4 %). At initial visit, a large majority (70%) of patients were authorized exclusively medical cannabis products, 27% were authorized a combination of pharmaceutical cannabinoids and medical cannabis and 3% were prescribed only pharmaceutical cannabinoids. This pattern was recurrent over the one-year follow-up. Overall, oil was the preferred formulation (average over visits 72.5%) followed by a combination of oil and dry (average 19%), other routes of administration accounted for less than 4%. Patients were predominantly prescribed products with a balanced THC:CBD ratio (59%-75% across visits). 28% of patients reported at least one adverse effect (AE) at the 3-month follow-up visit and 12% at the six-month FUP visit. 84.8% of total AEs were mild and transient. No serious AE was reported. Overall, the most common side effects reported were dizziness (11.95% of total AEs), drowsiness (11.4%), dry mouth (5.5%), nausea (4.8%), headaches (4.6%), cough (4.4%), anxiety (4.1%) and euphoria (3.5%). Other adverse effects accounted for less than 3% of total AE. Conclusion: Our results confirm that the primary area of clinical use for medical cannabis is in pain management. Patients in this cohort are largely utilizing plant-based cannabis oil products with a balanced ratio of THC:CBD. Reported adverse effects were mild and included dizziness and drowsiness. This real-world data confirms the tolerable safety profile of medical cannabis and suggests medical indications not yet validated in controlled clinical trials. Such data offers an important opportunity for the investigation of the long-term effects of cannabinoid exposure in real-life conditions. Real-world evidence can be used to direct clinical trial research efforts on specific indications and dosing patterns for product development.

Keywords: medical cannabis, safety, real-world data, Canada

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Authors: Sandeep Kumar Agrawal, Aditi Bhattacharya, Janvie Manhas, Krushna Bhatt, Yatin Kholakiya, Nupur Khera, Ajoy Roychoudhury, Sudip Sen

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Autologous cultured explants of human oral mucosal epithelial cells (OMEC) are a potential therapeutic modality for limbal stem cell deficiency (LSCD). Injury or inflammation of the ocular surface in the form of burns, chemicals, Stevens Johnson syndrome, ocular cicatricial pemphigoid etc. can lead to destruction and deficiency of limbal stem cells. LSCD manifests in the form of severe ocular surface diseases (OSD) characterized by persistent and recurrent epithelial defects, conjuntivalisation and neovascularisation of the corneal surface, scarring and ultimately opacity and blindness. Most of the cases of OSD are associated with severe dry eye pertaining to diminished mucin and aqueous secretion. Mycophenolate mofetil (MMF) has been shown to upregulate the mucin expression in conjunctival goblet cells in vitro. The aim of this study was to evaluate the effects of MMF on mucin expression in primary cultures of oral mucosal epithelial cells. With institutional ethics committee approval and written informed consent, thirty oral mucosal epithelial tissue samples were obtained from patients undergoing oral surgery for non-malignant conditions. OMEC were grown on human amniotic membrane (HAM, obtained from expecting mothers undergoing elective caesarean section) scaffold for 2 weeks in growth media containing DMEM & Ham’s F12 (1:1) with 10% FBS and growth factors. In vitro dosage of MMF was standardised by MTT assay. Analysis of stem cell markers was done using RT-PCR while mucin mRNA expression was quantified using RT-PCR and q-PCR before and after treating cultured OMEC with graded concentrations of MMF for 24 hours. Protein expression was validated using immunocytochemistry. Morphological studies revealed a confluent sheet of proliferating, stratified oral mucosal epithelial cells growing over the surface of HAM scaffold. The presence of progenitor stem cell markers (p63, p75, β1-Integrin and ABCG2) and cell surface associated mucins (MUC1, MUC15 and MUC16) were elucidated by RT-PCR. The mucin mRNA expression was found to be upregulated in MMF treated primary cultures of OMEC, compared to untreated controls as quantified by q-PCR with β-actin as internal reference gene. Increased MUC1 protein expression was validated by immunocytochemistry on representative samples. Our findings conclude that OMEC have the ability to form a multi-layered confluent sheet on the surface of HAM similar to a cornea, which is important for the reconstruction of the damaged ocular surface. Cultured OMEC has stem cell properties as demonstrated by stem cell markers. MMF can be a novel enhancer of mucin production in OMEC. It has the potential to improve dry eye in patients undergoing OMEC transplantation for bilateral OSD. Further clinical trials are required to establish the role of MMF in patients undergoing OMEC transplantation.

Keywords: limbal stem cell deficiency, mycophenolate mofetil, mucin, ocular surface disease

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Authors: Khlood F. Salman, Richard Zoucha, Hani Nawafleh

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Introduction: Jordan ranks the fourth highest breast cancer prevalence after Lebanon, Bahrain, and Kuwait. Considerable evidence showed that cultural, ethnic, and economic differences influence a woman’s practice to early detection and prevention of breast cancer. Objectives: To understand women’s health beliefs and values in relation to early detection of breast cancer; and to explore the impact of these beliefs on their decisions regarding reluctance or acceptance of early detection measures such as mammogram screening. Design: A qualitative focused ethnography was used to collect data for this study. Settings: The study was conducted in the second largest city surrounded by a large rural area in Ma’an- Jordan. Participants: A total of twenty seven women, with no history of breast cancer, between the ages of 18 and older, who had prior health experience with health providers, and were willing to share elements of personal health beliefs related to breast health within the larger cultural context. The participants were recruited using the snowball method and words of mouth. Data collection and analysis: A short questionnaire was designed to collect data related to socio demographic status (SDQ) from all participants. A Semi-structured interviews guide was used to elicit data through interviews with the informants. Nvivo10 a data manager was utilized to assist with data analysis. Leininger’s four phases of qualitative data analysis was used as a guide for the data analysis. The phases used to analyze the data included: 1) Collecting and documenting raw data, 2) Identifying of descriptors and categories according to the domains of inquiry and research questions. Emic and etic data is coded for similarities and differences, 3) Identifying patterns and contextual analysis, discover saturation of ideas and recurrent patterns, and 4) Identifying themes and theoretical formulations and recommendations. Findings: Three major themes were emerged within the cultural and religious context; 1. Fear, denial, embarrassment and lack of knowledge were common perceptions of Ma’anis’ women regarding breast health and screening mammography, 2. Health care professionals in Jordan were not quick to offer information and education about breast cancer and screening, and 3. Willingness to learn about breast health and cancer prevention. Conclusion: The study indicated the disparities between the infrastructure and resourcing in rural and urban areas of Jordan, knowledge deficit related to breast cancer, and lack of education about breast health may impact women’s decision to go for a mammogram screening. Cultural beliefs, fear, embarrassments as well as providers lack of focus on breast health were significant contributors against practicing breast health. Health providers and policy makers should provide resources for the establishment health education programs regarding breast cancer early detection and mammography screening. Nurses should play a major role in delivering health education about breast health in general and breast cancer in particular. A culturally appropriate health awareness messages can be used in creating educational programs which can be employed at the national levels.

Keywords: breast health, beliefs, cultural context, ethnography, mammogram screening

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Authors: Rao Singh Priyanka, Jayangondaperumal R.

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The Himalayan active fault has the potential to generate great earthquakes in the future, posing a biggest existential threat to humans in the Himalayan and adjacent region. Quantitative evaluation of accumulated and released interseismic strain is crucial to assess the magnitude and spatio-temporal variability of future great earthquakes along the Himalayan arc. To mitigate the destruction and hazards associated with such earthquakes, it is important to understand their recurrence cycle. The eastern Himalayan and Indo-Burman plate boundary systems offers an oblique convergence across two orthogonal plate boundaries, resulting in a zone of distributed deformation both within and away from the plate boundary and clockwise rotation of fault-bounded blocks. This seismically active region has poorly documented historical archive of the past large earthquakes. Thus, paleoseismologicalstudies confirm the surface rupture evidences of the great continental earthquakes (Mw ≥ 8) along the Himalayan Frontal Thrust (HFT), which along with the Geodetic studies, collectively provide the crucial information to understand and assess the seismic potential. These investigations reveal the rupture of 3/4th of the HFT during great events since medieval time but with debatable opinions for the timing of events due to unclear evidences, ignorance of transverse segment boundaries, and lack of detail studies. Recent paleoseismological investigations in the eastern Himalaya and Mishmi ranges confirms the primary surface ruptures of the 1950 C.E. great earthquake (M>8). However, a seismic gap exists between the 1714 C.E. and 1950 C.E. Assam earthquakes that did not slip since 1697 C.E. event. Unlike the latest large blind 2015 Gorkha earthquake (Mw 7.8), the 1950 C.E. event is not triggered by a large event of 1947 C.E. that occurred near the western edge of the great upper Assam event. Moreover, the western segment of the eastern Himalayadid not witness any surface breaking earthquake along the HFT for over the past 300 yr. The frontal fault excavations reveal that during the 1950 earthquake, ~3.1-m-high scarp along the HFT was formed due to the co-seismic slip of 5.5 ± 0.7 m at Pasighat in the Eastern Himalaya and a 10-m-high-scarp at a Kamlang Nagar along the Mishmi Thrust in the Eastern Himalayan Syntaxis is an outcome of a dip-slip displacement of 24.6 ± 4.6 m along a 25 ± 5°E dipping fault. This event has ruptured along the two orthogonal fault systems in the form of oblique thrust fault mechanism. Approx. 130 km west of Pasighat site, the Himebasti village has witnessed two earthquakes, the historical 1697 Sadiya earthquake, and the 1950 event, with a cumulative dip-slip displacement of 15.32 ± 4.69 m. At Niglok site, Arunachal Pradesh, a cumulative slip of ~12.82 m during at least three events since pre 19585 B.P. has produced ~6.2-m high scarp while the youngest scarp of ~2.4-m height has been produced during 1697 C.E. The site preserves two deformational events along the eastern HFT, providing an idea of last serial ruptures at an interval of ~850 yearswhile the successive surface rupturing earthquakes lacks in the Mishmi Range to estimate the recurrence cycle.

Keywords: paleoseismology, surface rupture, recurrence interval, Eastern Himalaya

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Authors: Delphine Ribes Lemay, Valentine Bernasconi, André Andrade, Lara DéFayes, Mathieu Salzmann, FréDéRic Kaplan, Nicolas Henchoz

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Digitization and preservation of large heritage induce high maintenance costs to keep up with the technical standards and ensure sustainable access. Creating impactful usage is instrumental to justify the resources for long-term preservation. The Museum für Gestaltung of Zurich holds one of the biggest poster collections of the world from which 52’000 were digitised. In the process of building a digital installation to valorize the collection, one objective was to develop an algorithm capable of predicting the next poster to show according to the ones already displayed. The work presented here describes the steps to build an algorithm able to automatically create sequences of posters reflecting associations performed by curator and professional designers. The exposed challenge finds similarities with the domain of song playlist algorithms. Recently, artificial intelligence techniques and more specifically, deep-learning algorithms have been used to facilitate their generations. Promising results were found thanks to Recurrent Neural Networks (RNN) trained on manually generated playlist and paired with clusters of extracted features from songs. We used the same principles to create the proposed algorithm but applied to a challenging medium, posters. First, a convolutional autoencoder was trained to extract features of the posters. The 52’000 digital posters were used as a training set. Poster features were then clustered. Next, an RNN learned to predict the next cluster according to the previous ones. RNN training set was composed of poster sequences extracted from a collection of books from the Gestaltung Museum of Zurich dedicated to displaying posters. Finally, within the predicted cluster, the poster with the best proximity compared to the previous poster is selected. The mean square distance between features of posters was used to compute the proximity. To validate the predictive model, we compared sequences of 15 posters produced by our model to randomly and manually generated sequences. Manual sequences were created by a professional graphic designer. We asked 21 participants working as professional graphic designers to sort the sequences from the one with the strongest graphic line to the one with the weakest and to motivate their answer with a short description. The sequences produced by the designer were ranked first 60%, second 25% and third 15% of the time. The sequences produced by our predictive model were ranked first 25%, second 45% and third 30% of the time. The sequences produced randomly were ranked first 15%, second 29%, and third 55% of the time. Compared to designer sequences, and as reported by participants, model and random sequences lacked thematic continuity. According to the results, the proposed model is able to generate better poster sequencing compared to random sampling. Eventually, our algorithm is sometimes able to outperform a professional designer. As a next step, the proposed algorithm should include a possibility to create sequences according to a selected theme. To conclude, this work shows the potentiality of artificial intelligence techniques to learn from existing content and provide a tool to curate large sets of data, with a permanent renewal of the presented content.

Keywords: Artificial Intelligence, Digital Humanities, serendipity, design research

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Authors: B. S. Premalatha, Kausalya Sahani

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Background: Glomus jugulare tumors arise within the jugular foramen and are commonly seen in females particularly on the left side. Surgical excision of the tumor may cause lower cranial nerve deficits. Cranial nerve involvement produces hoarseness of voice, slurred speech, and dysphagia along with other physical symptoms, thereby affecting the quality of life of individuals. Though oncological clearance is mainly emphasized on while treating these individuals, little importance is given to their communication, voice and swallowing problems, which play a crucial part in daily functioning. Objective: To examine the functions of voice, speech and swallowing outcomes of the subjects, following excision of glomus jugulare tumor. Methods: Two female subjects aged 56 and 62 years had come with a complaint of change in voice, inability to swallow and reduced clarity of speech following surgery for left glomus jugulare tumor were participants of the study. Their surgical information revealed multiple cranial nerve palsies involving the left facial, left superior and recurrent branches of the vagus nerve, left pharyngeal, left soft palate, left hypoglossal and vestibular nerves. Functional outcomes of voice, speech and swallowing were evaluated by perceptual and objective assessment procedures. Assessment included the examination of oral structures and functions, dysarthria by Frenchey dysarthria assessment, cranial nerve functions and swallowing functions. MDVP and Dr. Speech software were used to evaluate acoustic parameters of voice and quality of voice respectively. Results: The study revealed that both the subjects, subsequent to excision of glomus jugulare tumor, showed a varied picture of affected oral structure and functions, articulation, voice and swallowing functions. The cranial nerve assessment showed impairment of the vagus, hypoglossal, facial and glossopharyngeal nerves. Voice examination indicated vocal cord paralysis associated with breathy quality of voice, weak voluntary cough, reduced pitch and loudness range, and poor respiratory support. Perturbation parameters as jitter, shimmer were affected along with s/z ratio indicative of voice fold pathology. Reduced MPD(Maximum Phonation Duration) of vowels indicated that disturbed coordination between respiratory and laryngeal systems. Hypernasality was found to be a prominent feature which reduced speech intelligibility. Imprecise articulation was seen in both the subjects as the hypoglossal nerve was affected following surgery. Injury to vagus, hypoglossal, gloss pharyngeal and facial nerves disturbed the function of swallowing. All the phases of swallow were affected. Aspiration was observed before and during the swallow, confirming the oropharyngeal dysphagia. All the subsystems were affected as per Frenchey Dysarthria Assessment signifying the diagnosis of flaccid dysarthria. Conclusion: There is an observable communication and swallowing difficulty seen following excision of glomus jugulare tumor. Even with complete resection, extensive rehabilitation may be necessary due to significant lower cranial nerve dysfunction. The finding of the present study stresses the need for involvement of as speech and swallowing therapist for pre-operative counseling and assessment of functional outcomes.

Keywords: functional outcome, glomus jugulare tumor excision, multiple cranial nerve impairment, speech and swallowing

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Authors: Mahla Azimi

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Introduction: Post-bladder catheter infection is a common and significant healthcare-associated infection that affects individuals with indwelling urinary catheters. These infections can lead to various complications, including urinary tract infections (UTIs), bacteremia, sepsis, and increased morbidity and mortality rates. This article aims to provide a comprehensive review of post-bladder catheter infections, including their causes, risk factors, clinical presentation, diagnosis, treatment options, and preventive measures. Causes and Risk Factors: Post-bladder catheter infections primarily occur due to the colonization of microorganisms on the surface of the urinary catheter. The most common pathogens involved are Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Enterococcus species. Several risk factors contribute to the development of these infections, such as prolonged catheterization duration, improper insertion technique, poor hygiene practices during catheter care, compromised immune system function in patients with underlying conditions or immunosuppressive therapy. Clinical Presentation: Patients with post-bladder catheter infections may present with symptoms such as fever, chills, malaise, suprapubic pain or tenderness, and cloudy or foul-smelling urine. In severe cases or when left untreated for an extended period of time, patients may develop more severe symptoms like hematuria or signs of systemic infection. Diagnosis: The diagnosis of post-bladder catheter infection involves a combination of clinical evaluation and laboratory investigations. Urinalysis is crucial in identifying pyuria (presence of white blood cells) and bacteriuria (presence of bacteria). A urine culture is performed to identify the causative organism(s) and determine its antibiotic susceptibility profile. Treatment Options: Prompt initiation of appropriate antibiotic therapy is essential in managing post-bladder catheter infections. Empirical treatment should cover common pathogens until culture results are available. The choice of antibiotics should be guided by local antibiogram data to ensure optimal therapy. In some cases, catheter removal may be necessary, especially if the infection is recurrent or associated with severe complications. Preventive Measures: Prevention plays a vital role in reducing the incidence of post-bladder catheter infections. Strategies include proper hand hygiene, aseptic technique during catheter insertion and care, regular catheter maintenance, and timely removal of unnecessary catheters. Healthcare professionals should also promote patient education regarding self-care practices and signs of infection. Conclusion: Post-bladder catheter infections are a significant healthcare concern that can lead to severe complications and increased healthcare costs. Early recognition, appropriate diagnosis, and prompt treatment are crucial in managing these infections effectively. Implementing preventive measures can significantly reduce the incidence of post-bladder catheter infections and improve patient outcomes. Further research is needed to explore novel strategies for prevention and management in this field.

Keywords: post-bladder catheter infection, urinary tract infection, bacteriuria, indwelling urinary catheters, prevention

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Authors: Nilki Upathissa, Torin Wirasinghe

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This solution addresses the challenges faced by traditional bookstores and the limitations of digital media, striking a balance between the tactile experience of printed books and the convenience of modern technology. The book exchange system offers a sustainable alternative, empowering users to access a diverse range of books while promoting community engagement. The user-friendly interfaces incorporated into the book exchange system ensure a seamless and enjoyable experience for users. Intuitive features for book management, search, and messaging facilitate effortless exchanges and interactions between users. By streamlining the process, the system encourages readers to explore new books aligned with their interests, enhancing the overall reading experience. Central to the system's success is the hybrid recommendation engine, which leverages advanced technologies such as Long Short-Term Memory (LSTM) models. By analyzing user input, the engine accurately predicts genre preferences, enabling personalized book recommendations. The hybrid approach integrates multiple technologies, including user interfaces, machine learning models, and recommendation algorithms, to ensure the accuracy and diversity of the recommendations. The evaluation of the book exchange system with the hybrid recommendation engine demonstrated exceptional performance across key metrics. The high accuracy score of 0.97 highlights the system's ability to provide relevant recommendations, enhancing users' chances of discovering books that resonate with their interests. The commendable precision, recall, and F1score scores further validate the system's efficacy in offering appropriate book suggestions. Additionally, the curve classifications substantiate the system's effectiveness in distinguishing positive and negative recommendations. This metric provides confidence in the system's ability to navigate the vast landscape of book choices and deliver recommendations that align with users' preferences. Furthermore, the implementation of this book exchange system with a hybrid recommendation engine has the potential to revolutionize the way readers interact with printed books. By facilitating book exchanges and providing personalized recommendations, the system encourages a sense of community and exploration within the reading community. Moreover, the emphasis on sustainability aligns with the growing global consciousness towards eco-friendly practices. With its robust technical approach and promising evaluation results, this solution paves the way for a more inclusive, accessible, and enjoyable reading experience for book lovers worldwide. In conclusion, the developed book exchange system with a hybrid recommendation engine represents a progressive solution to the challenges faced by traditional bookstores and the limitations of digital media. By promoting sustainability, widening access to printed books, and fostering engagement with reading, this system addresses the evolving needs of book enthusiasts. The integration of user-friendly interfaces, advanced machine learning models, and recommendation algorithms ensure accurate and diverse book recommendations, enriching the reading experience for users.

Keywords: recommendation systems, hybrid recommendation systems, machine learning, data science, long short-term memory, recurrent neural network

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Authors: Lucille Alonso, Florent Renard

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The characterizations of urban heat island (UHI) and their interactions with climate change and urban climates are the main research and public health issue, due to the increasing urbanization of the population. These solutions require a better knowledge of the UHI and micro-climate in urban areas, by combining measurements and modelling. This study is part of this topic by evaluating microclimatic conditions in dense urban areas in the Lyon Metropolitan Area (France) using a combination of data traditionally used such as topography, but also from LiDAR (Light Detection And Ranging) data, Landsat 8 satellite observation and Sentinel and ground measurements by bike. These bicycle-dependent weather data collections are used to build the database of the variable to be modelled, the air temperature, over Lyon’s hyper-center. This study aims to model the air temperature, measured during 6 mobile campaigns in Lyon in clear weather, using multiple linear regressions based on 33 explanatory variables. They are of various categories such as meteorological parameters from remote sensing, topographic variables, vegetation indices, the presence of water, humidity, bare soil, buildings, radiation, urban morphology or proximity and density to various land uses (water surfaces, vegetation, bare soil, etc.). The acquisition sources are multiple and come from the Landsat 8 and Sentinel satellites, LiDAR points, and cartographic products downloaded from an open data platform in Greater Lyon. Regarding the presence of low, medium, and high vegetation, the presence of buildings and ground, several buffers close to these factors were tested (5, 10, 20, 25, 50, 100, 200 and 500m). The buffers with the best linear correlations with air temperature for ground are 5m around the measurement points, for low and medium vegetation, and for building 50m and for high vegetation is 100m. The explanatory model of the dependent variable is obtained by multiple linear regression of the remaining explanatory variables (Pearson correlation matrix with a |r| < 0.7 and VIF with < 5) by integrating a stepwise sorting algorithm. Moreover, holdout cross-validation is performed, due to its ability to detect over-fitting of multiple regression, although multiple regression provides internal validation and randomization (80% training, 20% testing). Multiple linear regression explained, on average, 72% of the variance for the study days, with an average RMSE of only 0.20°C. The impact on the model of surface temperature in the estimation of air temperature is the most important variable. Other variables are recurrent such as distance to subway stations, distance to water areas, NDVI, digital elevation model, sky view factor, average vegetation density, or building density. Changing urban morphology influences the city's thermal patterns. The thermal atmosphere in dense urban areas can only be analysed on a microscale to be able to consider the local impact of trees, streets, and buildings. There is currently no network of fixed weather stations sufficiently deployed in central Lyon and most major urban areas. Therefore, it is necessary to use mobile measurements, followed by modelling to characterize the city's multiple thermal environments.

Keywords: air temperature, LIDAR, multiple linear regression, surface temperature, urban heat island

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Authors: Olga Smilevska Spasova, Katerina Boshkovska, Gorica Popova, Mirjana Popovska

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Introduction: Pneumonia is an infection of the pulmonary parenchyma. HPIV 3 is one of four viruses that is a member of the Paramyxoviridae family designated types 1-4 that have a nonsegmented, single-stranded RNA genome with a lipid-containing envelope. They are spread from the respiratory tract by aerosolized secretions or by direct contact with secretions. Type 3 is endemic and can cause serious illness in immunocompromised patients. Illness caused by parainfluenza occurs shortly after inoculation with the virus. The level of immunoglobulin A antibody in serum is the best predictor of susceptibility to infection. Streptococcus pneumonia or pneumococcus is a Gram-positive, spherical bacteria, usually found in pairs and it is a member of the genus Streptococcus. Streptococcus pneumonia resides asymptomatically in healthy carriers typically colonizing the respiratory tract, sinuses, and nasal cavity. In individuals with weaker immune systems like young infants, pneumococcal bacterium is the most common cause of community-acquired pneumonia in the world. Case Report: The aim is to present a case of lower respiratory tract infection in an infant caused by parainfluenza virus 3, S. pneumonia and undifferentiated gram-negative bacteria that was successfully treated. The infant is with a history of recurrent episodes of wheezing in the past 3mounts.Infant of 10months presents 2weeks before admittance with high fever, runny nose, and cough. The primary pediatrician prescribed oral cefpodoxime for 10days and inhaled salbutamol. Two days before admittance in hospital the infant with high fever, cough, and difficulty breathing. At admittance, infant is pale, anxious with rapid respirations, cough, wheezing and tachycardia. On auscultation: vesicular breathing sounds with high pitched wheezing and on the right coarse crackles. Investigations: Blood analysis: RBC: 4, 7 x1012L, WBC: 8,3x109L: Neut: 42.73% Lym: 41.57%, Hgb: 9.38 g/dl MCV: 62.7fl, MCH: 20.0pg MCHC: 31.8 g/dl RDW: 18.7% Plt-307.9 x109LCRP: 2,5mg/l, serum iron-7.92umol/l, O2sat-97% on blood gas analysis, puls-125/min.X-ray of chest with hyperinflationand right pericardial consolidation. Microbiological analysis of sputum sample is positive for undifferentiated gram-negative bacteria (colonizer)–resistant to cefotaxime, ampicillin, cefoxitin, sulfamet.+trimetoprim and sensitive to amikacin, gentamicin, and ciprofloxacin. Molecular multiplex RT-PCR for 19 viruses and multiplex PCR for 7 bacteria test for respiratory pathogens positive for Parainfluenza virus 3(Ct=22.73), Streptococcus pneumonia (Ct=26.75).IED: IgG-9.31g/l, IgA-0.351g/l, IgM-0.86g/l. Therapy: Treatment was started with inhaled salbutamol, intravenous antibiotic cefotaxime as well as systemic corticosteroids. On day 7 because of slow clinical resolution of chest auscultation findings and an etiologic clue with a positive sputum sample for resistant undifferentiated gram negative bacteria, a second intravenous antibiotic was administered amikacin. The infant is discharged on day 14 with resolution of clinical findings. Conclusion: Mixed co-infections with respiratory viruses and bacteria in immunocompromised infants are likely to lead to a more severe form of community acquired pneumonia that will need hospitalization.

Keywords: HPIV- 3, infant, pneumonia, S. pneumonia, x-ray chest

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Authors: Ahmad Saad, Shuja Abbas, Breanna Marine

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Introduction: This study explores the potential applications of autologous pedal fat pad grafting as a minimally invasive therapeutic strategy for addressing pedal fat pad loss. Without adequate shock absorbing tissue, a patient can experience functional deficits, ulcerations, loss of quality of life, and significant limitations with ambulation. This study details a novel technique involving autologous adipose grafting from the abdomen to enhance plantar fat pad thickness in a patient involved in a severe motor vehicle accident which resulted in total fat pad loss of the heel. Autologous adipose grafting (AAG) was used following adipose allografting in an effort to recreate a normal shock absorbing surface to allow return to activities of daily living and painless ambulation. Methods: A 46-year-old male sustained multiple open pedal fractures and necrosis to the heel fat pad after a motorcycle accident, which resulted in complete loss of the calcaneal fat pad. The patient underwent serial debridement’s, utilization of wound vac therapy and split thickness skin grafting to accomplish complete closure, despite complete loss of adipose to area. Patient presented with complaints of pain on ambulation, inability to bear weight on the heel, recurrent ulcerations, admitted had not been ambulating for two years. Clinical exam demonstrated complete loss of the plantar fat pad with a thin layer of epithelial tissue overlying the calcaneal bone, allowing visibility of the osseous contour of the calcaneus. Scar tissue had formed in place of the fat pad, with thickened epithelial tissue extending from the midfoot to the calcaneus. After conservative measures were exhausted, the patient opted for initial management by adipose allograft matrix (AAM) injections. Post operative X-ray imaging revealed noticeable improvement in calcaneal fat pad thickness. At 1 year follow up, the patient was able to ambulate without assistive devices. The fat pad at this point was significantly thicker than it was pre-operatively, but the thickness did not restore to pre-accident thickness. In order to compare the take of allograft versus autografting of adipose tissue, the decision to use adipose autograft through abdominal liposuction harvesting was deemed suitable. A general surgeon completed harvesting of adipose cells from the patient’s abdomen via liposuction, and a podiatric surgeon performed the AAG injection into the heel. Total of 15 cc’s of autologous adipose tissue injected to the calcaneus. Results: There was a visual increase in the calcaneal fat pad thickness both clinically and radiographically. At the 6-week follow up, imaging revealed retention of the calcaneal fat pad thickness. Three months postop, patient returned to activities of daily living and increased quality of life due to their increased ability to ambulate. Discussion: AAG is a novel treatment for pedal fat pad loss. These treatments may be viable and reproducible therapeutic choices for patients suffering from fat pad atrophy, fat pad loss, and/or plantar ulcerations. Both treatments of AAM and AAG exhibited similar therapeutic results by providing pain relief for ambulation and allowing for patients to return to their quality of life.

Keywords: podiatry, wound, adipose, allograft, autograft, wound care, limb reconstruction, injection, limb salvage

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Authors: Humaira Saeed Malik, Salma Saad

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Introduction: Fowler's syndrome, first described by Clare Fowler in 1985, is a rare urological condition characterized by difficulty in urination due to the abnormal function of the urethral sphincter. It predominantly affects young women and leads to chronic urinary retention. The main concern in managing this condition is ensuring regular bladder emptying. Clam cystoplasty is a bladder augmentation surgery in which the bladder is clam-shelled open, and a segment of the intestine is used to increase the bladder's capacity and reduce bladder pressure. The Mitrofanoff procedure, a surgical creation of a continent urinary diversion, is often performed in patients with Fowler's syndrome who require long-term catheterization. This procedure involves creating a conduit (from the appendix or a segment of the small intestine) between the bladder and the skin, allowing for intermittent self-catheterization to manage urinary retention. Study: This case study examines a 39-year-old gravida 3, para 0+2 woman with a BMI of 40, Fowler's syndrome, type I diabetes, and post-traumatic stress disorder (PTSD), presenting at Dumfries and Galloway Royal Infirmary at 8 weeks of gestation. Diagnosed with Fowler's syndrome at 23, . A sacral nerve stimulator (SNS) device was initially placed but was subsequently removed after one year due to malfunction caused by trauma, subsequently she had undergone clam cystoplasty and the Mitrofanoff procedure for bladder management. Her pregnancy was complicated by vaginal bleeding at 10 weeks, treated with progesterone pessaries, and a urinary tract infection at 14 weeks, managed with antibiotics. Despite these challenges, she continued self-catheterization through the Mitrofanoff stoma and was placed on prophylactic antibiotics. Her diabetes was well-controlled on insulin, and a 20-week fetal anomaly scan was normal. The multidisciplinary team, including an obstetrician and a urologist, planned for serial growth scans and the initiation of low molecular weight heparin (LMWH) from 28 weeks due to the intermediate risk of venous thromboembolism (VTE) and to continue six weeks after delivery. A planned cesarean delivery at 37 weeks was arranged, with an MRI scan scheduled later in the pregnancy to assist in surgical planning, ensuring the preservation of the Mitrofanoff stoma's function. The surgery will occur in an elective setting and include a consultant urologist. Conclusion: Pregnancy in women with Fowler's syndrome who have undergone Clam cystoplasty and the Mitrofanoff procedure is rare, and management requires careful planning and a multidisciplinary approach. This case highlights the importance of individualized care plans and close monitoring of both mother and fetus. The patient's risk of recurrent UTIs, coupled with her diabetes and high BMI, necessitated coordinated care across specialties to ensure the best possible outcomes. The Mitrofanoff procedure proved effective in managing her urinary retention, allowing her to maintain self-catheterization during pregnancy. The multidisciplinary team approach was crucial in addressing her complex medical needs, involving obstetrics, urology, and endocrinology. This case adds valuable information to the limited literature on pregnancy management in patients with Fowler's syndrome who have undergone the Mitrofanoff procedure, highlighting the need for comprehensive, individualized care and the involvement of a multidisciplinary team to achieve the best results.

Keywords: fowler's syndrome, clam cystoplasty, mitrofanoff procedure, pregnancy

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Authors: Aleksandra Chałupnik, Zuzanna Chilimoniuk, Joanna Borowik, Aleksandra Borkowska, Anna Torres

Abstract:

Background: Precocious puberty is the occurrence of secondary sexual characteristics in girls before the age of 8. The diverse etiology of premature puberty is crucial to determine whether it is true precocious puberty, depending on the activation of the hypothalamic-pituitary-gonadal axis, or pseudo-precocious, which is independent of the activation of this axis. Whatever the cause, premature action of the sex hormones leads to the common symptoms of various forms of puberty. These include the development of sexual characteristics, acne, acceleration of growth rate and acceleration of skeletal maturation. Due to the possible genetic basis of the disorders, an interdisciplinary search for the cause is needed. Case report: The case report concerns a patient of a pediatric gynecology clinic who, at the age of two years, developed advanced thelarhe (M3) and started recurrent vaginal bleeding. In August 2019, gonadotropin suppression initially and after LHRH stimulation and high estradiol levels were reported at the Endocrinology Department. Imaging examinations showed a cyst in the right ovary projection. The bone age was six years. The entire clinical picture indicated pseudo- (peripheral) precocious in the course of ovarian autonomic cyst. In the follow-up ultrasound performed in September, the image of the cyst was stationary and normalization of estradiol levels and clinical symptoms was noted. In December 2019, cyst regression and normal gonadotropin and estradiol concentrations were found. In June 2020, white mucus tinged with blood on the underwear, without any other disturbing symptoms, was observed for several days. Two consecutive USG examinations carried out in the same month confirmed the change in the right ovary, the diameter of which was 25 mm with a very high level of estradiol. Germinal tumor markers were normal. On the Tanner scale, the patient scored M2P1. The labia and hymen had puberty features. The correct vaginal entrance was visible. Another active vaginal bleeding occurred in the first week of July 2020. The considered laparoscopic treatment was abandoned due to the lack of oncological indications. Treatment with Tamoxifen was recommended in July 2020. In the initiating period of treatment, no maturation progression, and even reduction of symptoms, no acceleration of growth and a marked reduction in the size of the cysts were noted. There was no bleeding. After the size of the cyst and hormonal activity increased again, the treatment was changed to Anastrozole, the effect of which led to a reduction in the size of the cyst. Conclusions: The entire clinical picture indicates alleged (peripheral) puberty. Premature puberty in girls, which is manifested as enlarged mammary glands with high levels of estrogens secreted by autonomic ovarian cysts and prepubertal levels of gonadotropins, may indicate McCune-Albright syndrome. Vaginal bleeding may also occur in this syndrome. Cancellation of surgical treatment of the cyst made it impossible to perform a molecular test that would allow to confirm the diagnosis. Taking into account the fact that cysts are often one of the first symptoms of McCune-Albrigt syndrome, it is important to remember about multidisciplinary care for the patient and careful search for skin and bone changes or other hormonal disorders.

Keywords: McCune Albrigth's syndrome, ovarian cyst, pediatric gynaecology, precocious puberty

Procedia PDF Downloads 191