Search results for: Jack L. Harris

Authors: Taylor Harris

Abstract:

Gustilo-anderson grade III tibial fractures are exquisitely difficult injuries to manage as they require extensive soft tissue repair in addition to fracture fixation. These injuries are best managed collaboratively by Orthopedic and Plastic surgeons. While utilizing an Orthoplastics approach has decreased the rates of adverse outcomes in these injuries, there is a large amount of variation in exactly how an Orthoplastics team approaches complex cases such as these. It is sometimes recommended that definitive bone fixation and soft tissue coverage be completed simultaneously in a single-stage manner, but there is a paucity of large scale studies to provide evidence to support this recommendation. It is the aim of this study to report the outcomes of a single-stage "fix-and-flap" approach through a systematic review of the available literature. Hopefully, this better informs an evidence-based Orthoplastics approach to managing open tibial fractures. Systematic review of the literature was performed. Medline and Google Scholar were used and all studies published since 2000, in English were included. 103 studies were initially evaluated for inclusion. Reference lists of all included studies were also examined for potentially eligible studies. Gustilo grade III tibial shaft fractures in adults that were managed with a single-stage Orthoplastics approach were identified and evaluated with regard to outcomes of interest. Exclusion criteria included studies with patients <16 years old, case studies, systemic reviews, meta-analyses. Primary outcomes of interest were the rates of deep infections and rates of limb salvage. Secondary outcomes of interest included time to bone union, rates of non-union, and rates of re-operation. 15 studies were eligible. 11 of these studies reported rates of deep infection as an outcome, with rates ranging from 0.98%-20%. The pooled rate between studies was 7.34%. 7 studies reported rates of limb salvage with a range of 96.25%-100%. The pooled rate of the associated studies was 97.8%. 6 reported rates of non-union with a range of 0%-14%, a pooled rate of 6.6%. 6 reported time to bone union with a range of 24 to 40.3 weeks and a pooled average time of 34.2 weeks, and 4 reported rates of reoperation ranging from 7%-55%, with a pooled rate of 31.1%. A few studies that compared a single stage to a multi stage approach side-by-side unanimously favored the single stage approach. Outcomes of Gustilo grade III open tibial fractures utilizing an Orthoplastics approach that is specifically done in a single-stage produce low rates of adverse outcomes. Large scale studies of Orthoplastic collaboration that were not completed in strictly a single stage, or were completed in multiple stages, have not reported as favorable outcomes. We recommend that not only should Orthopedic surgeons and Plastic surgeons collaborate in the management of severe open tibial fracture, but they should plan to undergo definitive fixation and coverage in a single-stage for improved outcomes.

Keywords: orthoplastic, gustilo grade iii, single-stage, trauma, systematic review

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Authors: Matthew Edmunds, Andrew Hunter, Clare Littlewood, Wisha Gul, Gabriel Heppenstall-Harris, Thomas Humphries

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Background: Revision courses for medical students undertaking their final examinations are commonplace throughout the UK. Traditionally these take the form of a series of lectures over multiple weeks or a single day of intensive lectures. The COVID-19 pandemic, however, has required medical educators to create new teaching formats to ensure they adhere to social distancing requirements. It has provided an unexpected opportunity to accelerate the development of students proficiency in the use of ‘technology-enabled communication platforms’, as mandated in the 2018 GMC Outcomes of Graduates. Recent advances in technology have made distance learning possible, whilst also providing novel and more engaging learning opportunities for students. Foundation Year 2 doctors at Aintree University Hospital developed an online series of videos to help prepare medical students in the North West and byond for their final medical school examinations. Method: Eight hour-long videos covering the key topics in medicine and surgery were posted on the Peer Learning Liverpool Youtube channel. These videos were created using new technology such as the screen and audio recording platform, Loom. Each video compromised at least 20 single best answer (SBA) questions, in keeping with the format in most medical school finals. Explanations of the answers were provided, and additional important material was covered. Students were able to ask questions by commenting on the videos, with the authors replying as soon as possible. Feedback was collated using an online Google form. Results: An average of 327 people viewed each video, with 113 students filling in the feedback form. 65.5% of respondents were within one month of their final medical school examinations. The average rating for how well prepared the students felt for their finals was 6.21/10 prior to the course and 8.01/10 after the course. A paired t-test demonstrated a mean increase of 1.80 (95% CI 1.66-1.93). Overall, 98.2% said the online format worked well or very well, and 99.1% would recommend the course to a peer. Conclusions: Based on the feedback received, the online revision course was successful both in terms of preparing students for their final examinations, and with regards to how well the online format worked. Free-text qualitative feedback highlighted advantages such as; students could learn at their own pace, revisit key concepts important to them, and practice exam style questions via the case-based format. Limitations identified included inconsistent audiovisual quality, and requests for a live online Q&A session following the conclusion of the course. This course will be relaunched later in the year with increased opportunities for students to access live feedback. The success of this online course has shown the roll that technology can play in medical education. As well as providing novel teaching modes, online learning allows students to access resources that otherwise would not be available locally, and ensure that they do not miss out on teaching that was previously provided face to face, in the current climate of social distancing.

Keywords: COVID-19 pandemic, Medical School, Online learning, Revision course

Procedia PDF Downloads 153

Authors: Lindsey D. Sams, Dean R. Gorman, Cathy D. Lirgg, Steve W. Dittmore, Jack C. Kern

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Golf is a lifetime sport that provides numerous physical and psychological benefits. The game has struggled with attrition and retention within minority groups and this has exposed the lack of a modified introduction to the game that is uniformly accessible and developmentally appropriate. Factors that have been related to sport participatory behaviors include perceived competence, enjoyment and intention. The purpose of this study was to examine self-reported perception differences in competence and enjoyment between learners using modified and traditional equipment as well as the potential effects these factors could have on intent for future participation. For this study, SNAG Golf was chosen to serve as the scaled equipment used by the modified equipment group. The participants in this study were 99 children (24 traditional equipment users/ 75 modified equipment users) located across the U.S. with ages ranging from 7 to 12 years (2nd-5th grade). Utilizing a convenience sampling method, data was obtained on a voluntary basis through surveys measuring children’s golf participation and self-perceptions concerning perceived competence, enjoyment and intention to continue participation. The scales used for perceived competence and enjoyment included Susan Harter’s Self-Perception Profile for Children (SPPC) along with the Physical Activity Enjoyment Scale (PACES). Analysis revealed no significant differences for enjoyment, perceived competence or intention between children learning with traditional golf equipment and modified golf equipment. This was true even though traditional equipment users reported significantly higher experience levels than that of modified users. Intention was regressed on the enjoyment and perceived competence variables. Congruent with current literature, enjoyment was a strong predictor of intention to continue participation, for both groups. Modified equipment users demonstrated significantly lower experience levels but reported similar levels of competence, enjoyment and intent to continue participation as reported by the more experienced, and potentially more skilled, traditional users. The ability to immediately generate these positive affects suggests the potential adoption of a more effective way to learn golf and a method that is conducive to participatory behaviors related to attrition and retention. These implications in turn, highlight an equipment candidate ideal for inception into physical education programs where new learners are introduced to various sports in safe and developmentally appropriate environments. A major goal of this study was to provide foundational research that instigates the further examination of golf’s introductory teaching methodologies, as there is a lack of its presence in current literature. Future research recommendations range from improvements in the current research design to expansive approaches related to the topic, such as progressive skill development, knowledge of the game’s tactical and strategic concepts, playing ability and teaching effectiveness when utilizing modified versus traditional equipment.

Keywords: adaptive sports, enjoyment, golf participation, modified equipment, perceived competence, SNAG golf

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Authors: Sarah A. Harris, Fleur L. McIntyre, Paola T. Chivers, Benjamin G. Piggott, Fiona H. Farringdon

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Australian Rules Football (ARF) is an invasion based, contact field sport with over one million participants. The contact nature of the game increases exposure to all injuries, including head trauma. Evidence suggests that both concussion and sub-concussive traumas such as head knocks may damage the brain, in particular the prefrontal cortex. The prefrontal cortex may not reach full maturity until a person is in their early twenties with males taking longer to mature than females. Repeated trauma to the pre-frontal cortex during maturation may lead to negative social, cognitive and emotional effects. It is also during this period that males exhibit high levels of risk taking behaviours. Risk propensity and the incidence of injury is an unexplored area of research. Little research has considered if the level of player’s (especially younger players) risk propensity in everyday life places them at an increased risk of injury. Hence the current study, investigated if a relationship exists between risk propensity and self-reported injuries including diagnosed concussion and head knocks, among male ARF players aged 18 to 31 years. Method: The study was conducted over 22 weeks with one West Australian Football League (WAFL) club during the 2015 competition. Pre-season risk propensity was measured using the 7-item self-report Risk Propensity Scale. Possible scores ranged from 9 to 63, with higher scores indicating higher risk propensity. Players reported their self-perceived injuries (concussion, head knocks, upper body and lower body injuries) fortnightly using the WAFL Injury Report Survey (WIRS). A unique ID code was used to ensure player anonymity, which also enabled linkage of survey responses and injury data tracking over the season. A General Linear Model (GLM) was used to analyse whether there was a relationship between risk propensity score and total number of injuries for each injury type. Results: Seventy one players (N=71) with an age range of 18.40 to 30.48 years and a mean age of 21.92 years (±2.96 years) participated in the study. Player’s mean risk propensity score was 32.73, SD ±8.38. Four hundred and ninety five (495) injuries were reported. The most frequently reported injury was head knocks representing 39.19% of total reported injuries. The GLM identified a significant relationship between risk propensity and head knocks (F=4.17, p=.046). No other injury types were significantly related to risk propensity. Discussion: A positive relationship between risk propensity and head trauma in contact sports (specifically WAFL) was discovered. Assessing player’s risk propensity therefore, may identify those more at risk of head injuries. Potentially leading to greater monitoring and education of these players throughout the season, regarding self-identification of head knocks and symptoms that may indicate trauma to the brain. This is important because many players involved in WAFL are in their late teens or early 20’s hence, may be at greater risk of negative outcomes if they experience repeated head trauma. Continued education and research into the risks associated with head injuries has the potential to improve player well-being.

Keywords: football, head injuries, injury identification, risk

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Authors: Suliman Al-Fayoumi, Sherri Amberg, Huafeng Zhou, Jack W. Singer, James P. Dean

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Pacritinib is an oral kinase inhibitor with specificity for JAK2, FLT3, IRAK1, and CSF1R. In clinical studies, pacritinib was well tolerated with clinical activity in patients with myelofibrosis. The most frequent adverse events (AEs) observed with pacritinib are gastrointestinal (diarrhea, nausea, and vomiting; mostly grade 1-2 in severity) and typically resolve within 2 weeks. A human ADME mass balance study demonstrated that pacritinib is predominantly cleared via hepatic metabolism and biliary excretion (>85% of administered dose). The major hepatic metabolite identified, M1, is not thought to materially contribute to the pharmacological activity of pacritinib. Hepatic diseases are known to impair hepatic blood flow, drug-metabolizing enzymes, and biliary transport systems and may affect drug absorption, disposition, efficacy, and toxicity. This phase 1 study evaluated the pharmacokinetics (PK) and safety of pacritinib and the M1 metabolite in study subjects with mild, moderate, or severe hepatic impairment (HI) and matched healthy subjects with normal liver function to determine if pacritinib dosage adjustments are necessary for patients with varying degrees of hepatic insufficiency. Study participants (aged 18-85 y) were enrolled into 4 groups based on their degree of HI as defined by Child-Pugh Clinical Assessment Score: mild (n=8), moderate (n=8), severe (n=4), and healthy volunteers (n=8) matched for age, BMI, and sex. Individuals with concomitant renal dysfunction or progressive liver disease were excluded. A single 400 mg dose of pacritinib was administered to all participants. Blood samples were obtained for PK evaluation predose and at multiple time points postdose through 168 h. Key PK parameters evaluated included maximum plasma concentration (Cmax), time to Cmax (Tmax), area under the plasma concentration time curve (AUC) from hour zero to last measurable concentration (AUC0-t), AUC extrapolated to infinity (AUC0-∞), and apparent terminal elimination half-life (t1/2). Following treatment, pacritinib was quantifiable for all study participants at 1 h through 168 h postdose. Systemic pacritinib exposure was similar between healthy volunteers and individuals with mild HI. However, there was a significant difference between those with moderate and severe HI and healthy volunteers with respect to peak concentration (Cmax) and plasma exposure (AUC0-t, AUC0-∞). Mean Cmax decreased by 47% and 57% respectively in participants with moderate and severe HI vs matched healthy volunteers. Similarly, mean AUC0-t decreased by 36% and 45% and mean AUC0-∞ decreased by 46% and 48%, respectively in individuals with moderate and severe HI vs healthy volunteers. Mean t1/2 ranged from 51.5 to 74.9 h across all groups. The variability on exposure ranged from 17.8% to 51.8% across all groups. Systemic exposure of M1 was also significantly decreased in study participants with moderate or severe HI vs. healthy participants and individuals with mild HI. These changes were not significantly dissimilar from the inter-patient variability in these parameters observed in healthy volunteers. All AEs were grade 1-2 in severity. Diarrhea and headache were the only AEs reported in >1 participant (n=4 each). Based on these observations, it is unlikely that dosage adjustments would be warranted in patients with mild, moderate, or severe HI treated with pacritinib.

Keywords: pacritinib, myelofibrosis, hepatic impairment, pharmacokinetics

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Authors: Alexis D'Agostino, Celeste Sununtunasuk, Jack Fiedler

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Background: Iron-folic acid (IFA) supplementation during antenatal care (ANC) has existed in many countries for decades. Despite this, low national coverage persists and women do not often consume appropriate amounts during pregnancy. USAID’s SPRING Project investigated pregnant women’s access to, and consumption of, IFA tablets through ANC. Cross-country analysis provided a global picture of the state of IFA-supplementation, while country-specific results noted key contextual issues, including geography, wealth, and ANC attendance. The analysis can help countries prioritize strategies for systematic performance improvements within one of the most common micronutrient supplementation programs aimed at reducing maternal anemia. Methodology: Using falter point analysis on Demographic and Health Survey (DHS) data collected from 162,958 women across 22 countries, SPRING identified four sequential falter points (ANC attendance, IFA receipt or purchase, IFA consumption, and number of tablets taken) where pregnant women fell out of the IFA distribution structure. SPRING analyzed data on IFA intake from DHS surveys with women of reproductive age. SPRING disaggregated these data by ANC participation during the most recent pregnancy, residency, and women’s socio-economic status. Results: Average sufficient IFA tablet use across all countries was only eight percent. Even in the best performing countries, only about one-third of pregnant women consumed 180 or more IFA tablets during their most recent pregnancy. ANC attendance was an important falter point for a quarter of women across all countries (with highest falter rates in Democratic Republic of the Congo, Nigeria, and Niger). Further analysis reveals patterns, with some countries having high ANC coverage but low IFA provision during ANC (DRC and Haiti), others having high ANC coverage and IFA provision but few women taking any tablets (Nigeria and Liberia), and countries that perform well in ANC, supplies, and initial consumption but where very few women consume the recommended 180 tablets (Malawi and Cambodia). Country-level analysis identifies further patterns of supplementation. In Indonesia, for example, only 62% of women in the poorest quintile took even one IFA tablet, while 86% of the wealthiest women did. This association between socioeconomic status and IFA intake held across nearly all countries where these data are available and was also visible in rural/urban comparisons. Analysis of ANC attendance data also suggests that higher numbers of ANC visits are associated with higher tablet intake. Conclusions: While it is difficult to disentangle which specific aspects of supply or demand cause the low rates of consumption, this tool allows policy-makers to identify major bottlenecks to scaling-up IFA supplementation during ANC. In turn, each falter point provides possible explanations of program performance and helps strategically identify areas for improved IFA supplementation. For example, improving the delivery of IFA supplementation in Ethiopia relies on increasing access to ANC, but also on identifying and addressing program gaps in IFA supply management and health workers’ practices in order to provide quality ANC services. While every country requires a customized approach to improving IFA supplementation, the multi-country analysis conducted by SPRING is a helpful first step in identifying country bottlenecks and prioritizing interventions.

Keywords: iron and folic acid, supplementation, antenatal care, micronutrient

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Authors: Esha Thakkar, Ina Liu, Kalynn Hosea, Shana Katz, Katie Marks, Sarah Hall, Cat Liu, Suzanne Harris

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Purpose: Inequities in mental healthcare accessibility are cited as an international public health concern by the World Health Organization (WHO) and National Alliance on Mental Illness (NAMI). These disparities are further exacerbated in racial and ethnic minority groups and are especially concerning in health professional training settings such as Doctor of Pharmacy (PharmD) programs and postgraduate residency training where mental illness rates are high. The purpose of the study was to determine baseline access to culturally sensitive mental healthcare and how to improve such access and communication for racially and ethnically minoritized pharmacy students and residents at one school of pharmacy and a partnering academic medical center in the United States. Methods: This IRB-exempt study included 60-minute focus groups conducted in person or online from November 2021 to February 2022. Eligible participants included PharmD students in their first (P1), second (P2), third (P3), or fourth year (P4) or pharmacy residents completing a postgraduate year 1 (PGY1) or PGY2 who identify as Black, Indigenous, or Person of Color (BIPOC). There were four core theme questions asked during the focus groups to lead the discussion, specifically on the core themes of personal barriers, identities, areas that are working well, and areas for improvement. Participant responses were transcribed and analyzed using an open coding system with two individual reviews, followed by collaborative and intentional discussion and, as needed, an external audit of the coding by a third research team member to reach a consensus on themes. Results: This study enrolled 26 participants, with eight P1, five P2, seven P3, two P4, and four resident participants. Within the four core themes of barriers, identities, areas working well, and areas for improvement, emerging subthemes included: lack of time, access to resources, and stigma under barriers; lack of representation, cultural and family stigma, and gender identities for identity barriers; supportive faculty, sense of community and culture supporting paid time off for areas going well; and wellness days, reduced workload and diversity of the workforce in areas of improvement. Subthemes sometimes varied within a core theme depending on the participant year. Conclusions: There is a gap in the literature in addressing barriers and disparities in mental health access for pharmacy trainees who identify as BIPOC. We identified key findings in regards to barriers, identities, areas going well and areas for improvement that can inform the School and the Residency Program in two priority initiatives of well-being and diversity equity and inclusion in creating actionable recommendations for trainees, program directors, and employers of our institutions, and also has the potential to provide insight for other organizations about the structures influencing access to culturally sensitive care in BIPOC trainees. These findings can inform organizations on how to continue building on communication with those who identify as BIPOC and improve access to care.

Keywords: mental health, disparities, minorities, wellbeing, identity, communication, barriers

Procedia PDF Downloads 92

Authors: Bryana Woodard, Monica Mitchell, Kasey Harry, Ebony Washington, Megan Harris, Marcia Boyd, Regina Lynch, Daphene Baines, Surbi Bankar

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Introduction: African Americans experience mental health illnesses (i.e., depression, anxiety, etc.) at higher rates than their white counterparts. Despite this, they utilize mental health resources less and have lower mental health literacy, perhaps due to cultural barriers- including but not limited to mistrust. Research acknowledges African Americans’ close ties to community networks, identifying these linkages as key to establishing comfort and trust. Similarly, the church has historically been a space that creates unity and community among African Americans. Studies show that longstanding academic-community partnerships with organizations, such as churches and faith-based entities, have the capability to effectively address health and mental health barriers and needs in African Americans. The importance of implementing faith-based approaches is supported in the literature, however few empirical studies exist. This project describes the First Ladies for Health and Cincinnati Children's Hospital Medical Center (CCHMC) Partnership (FLFH-CCHMC Partnership) and the implementation and assessment of an annual Mental Health Symposium, the overall aim of which was to increase mental health awareness and decrease stigma in African American communities. Methods: The specific goals of the FLFH Mental Health Symposium were to (1) Collaborate with trusted partners to build trust with community participants; (2) Increase mental health literacy and decrease mental health stigma; (3) Understand the barriers to improving mental health and improving trust; (4) Assess the short-term outcomes two months following the symposium. Data were collected through post-event and follow-up surveys using a mixed methods approach. Results: More than 100 participants attended each year with over 350 total participants over three years. 98.7% of participants were African American, 86.67% female, 11.6% male, and 11.6% LGBTQ+/non-binary; 10.5% of participants were teens, with the remainder aged 20 to 80 plus. The event was successful in achieving its goals: (1a) Eleven different speakers from 8 community and church organizations presented; (1b) 93% of participants rated the overall symposium as very good or excellent (2a) Mental health literacy significantly increased each year with over 90% of participants reporting improvement in their “understanding” and “awareness of mental health (2b) Participants 'personal stigma surrounding mental health illness decreased each year with 92.3% of participants reporting changes in their “willingness to talk about and share” mental health challenges; (3) Barriers to mental health care were identified and included social stigma, lack of trust, and the cost of care. Data were used to develop priorities and an action plan for the FLFH-CCHMC Mental Health Partnership; (4) Follow-up data showed that participants sustained benefits of the FLFH Symposium and took actionable steps (e.g., meditation, referrals, etc.). Additional quantitative and qualitative data will be shared. Conclusions: Lower rates of mental health literacy and higher rates of stigma among participants in this initiative demonstrate the importance of mental health providers building trust and partnerships in communities. Working with faith-based entities provides an opportunity to mitigate and address mental health equity in African American communities.

Keywords: community psychology, faith-based, african-american, culturally competent care, mental health equity

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Authors: Rosie Cooper, Tracey Chantler, Ellen Pringle, Sadie Bell, Emily Edmundson, Heidi Nielsen, Sheila Roberts, Michael Edelstein, Sandra Mounier Jack

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Introduction: In line with the National Health Service’s (NHS) long-term plan, the NHS is looking to implement more digital health interventions. This study explores a case study in this area: a digital intervention used by NHS Trusts in London to consent adolescents for Human Papilloma Virus (HPV) immunisation. Methods: The electronic consent intervention was implemented in 14 secondary schools in inner city, London. These schools were statistically matched with 14 schools from the same area that were consenting using paper forms. Schools were matched on deprivation and English as an additional language. Consent form return rates and HPV vaccine uptake were compared quantitatively between intervention and matched schools. Data from observations of immunisation sessions and school feedback forms were analysed thematically. Individual and group interviews were undertaken with implementers parents and adolescents and a focus group with adolescents were undertaken and analysed thematically. Results: Twenty-eight schools (14 e-consent schools and 14 paper consent schools) comprising 3219 girls (1733 in paper consent schools and 1486 in e-consent schools) were included in the study. The proportion of pupils eligible for free school meals, with English as an additional language and students' ethnicity profile, was similar between the e-consent and paper consent schools. Return of consent forms was not increased by the implementation of the e-consent intervention. There was no difference in the proportion of pupils that were vaccinated at the scheduled vaccination session between the paper (n=14) and e-consent (n=14) schools (80.6% vs. 81.3%, p=0.93). The transition to using the system was not straightforward, whilst schools and staff understood the potential benefits, they found it difficult to adapt to new ways of working which removed some level or control from schools. Part of the reason for lower consent form return in e-consent schools was that some parents found the intervention difficult to use due to limited access to the internet, finding it hard to open the weblink, language barriers, and in some cases, the system closed a few days prior to sessions. Adolescents also highlighted the potential for e-consent interventions to by-pass their information needs. Discussion: We would advise caution against dismissing the e-consent intervention because it did not achieve its goal of increasing the return of consent forms. Given the problems embedding a news service, it was encouraging that HPV vaccine uptake remained stable. Introducing change requires stakeholders to understand, buy in, and work together with others. Schools and staff understood the potential benefits of using e-consent but found the new ways of working removed some level of control from schools, which they found hard to adapt to, possibly suggesting implementing digital technology will require an embedding process. Conclusion: The future direction of the NHS will require implementation of digital technology. Obtaining electronic consent from parents could help streamline school-based adolescent immunisation programmes. Findings from this study suggest that when implementing new digital technologies, it is important to allow for a period of embedding to enable them to become incorporated in everyday practice.

Keywords: consent, digital, immunisation, prevention

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Authors: Mansoor Mohammed Abdu Al-Gabali

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This paper addresses the growing interest among non-Arab individuals in understanding the realities of Arab peoples and their cultures. The global media, particularly after the September 11 attacks, has contributed to negative and misrepresentative portrayals of Arabs. The paper aims to critically analyze various representations of identity, culture, and politics in the works of three contemporary Arab and Arab-American women writers. By exploring the perspectives and attitudes of these writers, the paper aims to challenge and rectify the misrepresentation created by the media and foster mutual understanding between Arab and American societies. Research Aim: The aim of this research is to examine the writings of Arab and Arab-American women in order to highlight the strengths and awareness of Arab cultures. It seeks to show how these writers create spaces for responding to the misrepresentation perpetuated by the media. The research contributes to bridging the gaps between Arab and American societies and fostering better mutual understanding. Methodology: This paper adopts a multidisciplinary approach, drawing on theoretical concepts from cultural studies. It also utilizes an inductive historical methodology to trace the works under study. The combination of these approaches allows for a comprehensive analysis of the representations of Arab peoples and cultures. Findings: The paper argues that the writings of Arab and Arab-American women demonstrate a multiplicity of perspectives and attitudes toward contemporary issues. It highlights the richness and diversity of their writing, as well as the connections they make between different periods of history and various sites of representation. The paper concludes that these writings transcend personal stories to incorporate broader national and global dialogues, emphasizing the commonalities shared by humanity and the socially contextualized issues that deserve respect. Theoretical Importance: This research holds theoretical importance in the field of cultural studies. It builds upon the works of scholars such as Jack Shaeen and Evelyn Alsultany, that have documented and critiqued the negative media representations of Arabs. By examining the writings of Arab and Arab-American women, this paper contributes to the theoretical understanding of cultural responses to media misrepresentation and the creation of spaces for mutual understanding. Data Collection and Analysis Procedures: The data collection for this research involved a thorough examination and analysis of the selected works by Elmaz Abinader, Diana Abu-Jaber, and Rajaa Al-Sanea. These works were scrutinized to identify the unique ways in which they tackled contemporary issues prevalent in Arab and Arab-American societies. Through close textual analysis and the application of cultural theories, the researchers were able to discern the underlying themes and messages conveyed in the writings. Question Addressed: The primary question addressed in this research is, "How do the writings of Arab and Arab-American women respond to the misrepresentation of Arab cultures in the media?" By exploring this question, the paper aims to shed light on the strengths and awareness of Arab cultures and to promote a more comprehensive understanding between Arabs and non-Arabs. Conclusion: This research concludes that the writings of Arab and Arab-American women serve as mediators between Arab and American cultures in response to the misrepresentation created by the media. These writings go beyond personal narratives, addressing broader social and cultural issues and seeking to highlight the commonalities shared by all human beings. The paper emphasizes the need for mutual respect and understanding in order to bridge the gaps between Arab and American societies and rectify the negative images that have been perpetuated in the media.

Keywords: Arabs, films, media, negotiation

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Authors: Parag Katira, Frederika Rentzeperis, Zuzanna Nowicka, Giada Fiandaca, Thomas Veith, Jack Farinhas, Noemi Andor

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Resource limitations shape the outcome of competitions between genetically heterogeneous pre-malignant cells. One example of such heterogeneity is in the ploidy (DNA content) of pre-malignant cells. A whole-genome duplication (WGD) transforms a diploid cell into a tetraploid one and has been detected in 28-56% of human cancers. If a tetraploid subclone expands, it consistently does so early in tumor evolution, when cell density is still low, and competition for nutrients is comparatively weak – an observation confirmed for several tumor types. WGD+ cells need more resources to synthesize increasing amounts of DNA, RNA, and proteins. To quantify resource limitations and how they relate to ploidy, we performed a PAN cancer analysis of WGD, PET/CT, and MRI scans. Segmentation of >20 different organs from >900 PET/CT scans were performed with MOOSE. We observed a strong correlation between organ-wide population-average estimates of Oxygen and the average ploidy of cancers growing in the respective organ (Pearson R = 0.66; P= 0.001). In-vitro experiments using near-diploid and near-tetraploid lineages derived from a breast cancer cell line supported the hypothesis that DNA content influences Glucose- and Oxygen-dependent proliferation-, death- and migration rates. To model how subpopulations with variable DNA content compete in the resource-limited environment of the human brain, we developed a stochastic state-space model of the brain (S3MB). The model discretizes the brain into voxels, whereby the state of each voxel is defined by 8+ variables that are updated over time: stiffness, Oxygen, phosphate, glucose, vasculature, dead cells, migrating cells and proliferating cells of various DNA content, and treat conditions such as radiotherapy and chemotherapy. Well-established Fokker-Planck partial differential equations govern the distribution of resources and cells across voxels. We applied S3MB on sequencing and imaging data obtained from a primary GBM patient. We performed whole genome sequencing (WGS) of four surgical specimens collected during the 1ˢᵗ and 2ⁿᵈ surgeries of the GBM and used HATCHET to quantify its clonal composition and how it changes between the two surgeries. HATCHET identified two aneuploid subpopulations of ploidy 1.98 and 2.29, respectively. The low-ploidy clone was dominant at the time of the first surgery and became even more dominant upon recurrence. MRI images were available before and after each surgery and registered to MNI space. The S3MB domain was initiated from 4mm³ voxels of the MNI space. T1 post and T2 flair scan acquired after the 1ˢᵗ surgery informed tumor cell densities per voxel. Magnetic Resonance Elastography scans and PET/CT scans informed stiffness and Glucose access per voxel. We performed a parameter search to recapitulate the GBM’s tumor cell density and ploidy composition before the 2ⁿᵈ surgery. Results suggest that the high-ploidy subpopulation had a higher Glucose-dependent proliferation rate (0.70 vs. 0.49), but a lower Glucose-dependent death rate (0.47 vs. 1.42). These differences resulted in spatial differences in the distribution of the two subpopulations. Our results contribute to a better understanding of how genomics and microenvironments interact to shape cell fate decisions and could help pave the way to therapeutic strategies that mimic prognostically favorable environments.

Keywords: tumor evolution, intra-tumor heterogeneity, whole-genome doubling, mathematical modeling

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Authors: Siti Rahayu, Khairulniza Mohd Puat, Kesavan R., Mohammad Harris A., Jalila, Kunalan G., Fazir Mohamad

Abstract:

The greatest challenge has been in establishing and maintaining the dedicated nursing team. Continuity is served when nurses are assigned exclusively for managing wound, where they can continue to build expertise and skills. In addition, there is a growing incidence of chronic wounds and recognition of the complexity involved in caring for these patients. We would like to share 4 cases with different techniques of wound management. 1st case, 39 years old gentleman with underlying rheumatoid arthritis with chronic periprosthetic joint infection of right total knee replacement presented with persistent drainage over right knee. Patient was consulted for two stage revision total knee replacement. However, patient only agreed for debridement and retention of implant. After debridement, large medial and lateral wound was treated with Instillation Negative Pressure Wound Therapy Dressings. After several cycle, the wound size reduced, and conventional dressing was applied. 2nd case, 58 years old gentleman with underlying diabetes presented with right foot necrotizing fasciitis with gangrene of 5th toe. He underwent extensive debridement of foot with rays’ amputation of 5th toe. Post debridement patient was started on Instillation Negative Pressure Wound Therapy Dressings. After several cycle of VAC, the wound bed was prepared, and he underwent split skin graft over right foot. 3 rd case, 60 years old gentleman with underlying diabetes mellitus presented with right foot necrotizing soft tissue infection. He underwent rays’ amputation and extensive wound debridement. Upon stabilization of general condition, patient was discharge with regular wound dressing by same nurse and doctor during each visit to clinic follow up. After 6 months of follow up, the wound healed well. 4th case, 38-year-old gentleman had alleged motor vehicle accident and sustained closed fracture right tibial plateau. Open reduction and proximal tibial locking plate were done. At 2 weeks post-surgery, the patient presented with warm, erythematous leg and pus discharge from the surgical site. Empirical antibiotic was started, and wound debridement was done. Intraoperatively, 50cc pus was evacuated, unhealthy muscle and tissue debrided. No loosening of the implant. Patient underwent multiple wound debridement. At 2 weeks post debridement wound healed well, but the proximal aspect was unable to close immediately. This left the proximal part of the implant to be exposed. Patient was then put on VAC dressing for 3 weeks until healthy granulation tissue closes the implant. Meanwhile, antibiotic was change according to culture and sensitivity. At 6 weeks post the first debridement, the wound was completely close, and patient was discharge home well. At 3 months post operatively, patient wound and fracture healed uneventfully and able to ambulate independently. Complex wounds are too serious to be dealt with. Team managing complex wound need continuous support through the provision of educational tools to support their professional development, engagement with local and international expert, as well as highquality products that increase efficiencies in services

Keywords: VAC (Vacuum Assisted Closure), empirical- initial antibiotics, NPWT- negative pressure wound therapy, NF- necrotizing fasciitis, gangrene- blackish discoloration due to poor blood supply

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Authors: Tim Crocker-Buque, Sandra Mounier-Jack, Natasha Howard

Abstract:

Background: Due to both the increasing scale and speed of urbanisation, urban areas in low and middle-income countries (LMICs) host increasingly large populations of under-immunized children, with the additional associated risks of rapid disease transmission in high-density living environments. Multiple interdependent factors are associated with these coverage disparities in urban areas and most evidence comes from relatively few countries, e.g., predominantly India, Kenya, Nigeria, and some from Pakistan, Iran, and Brazil. This study aimed to identify, describe, and assess the main tools used to measure or improve coverage of immunisation services in poor urban areas. Methods: Authors used a qualitative review design, including academic and non-academic literature, to identify tools used to improve coverage of public health interventions in urban areas. Authors selected and extracted sources that provided good examples of specific tools, or categories of tools, used in a context relevant to urban immunization. Diagnostic (e.g., for data collection, analysis, and insight generation) and programme tools (e.g., for investigating or improving ongoing programmes) and interventions (e.g., multi-component or stand-alone with evidence) were selected for inclusion to provide a range of type and availability of relevant tools. These were then prioritised using a decision-analysis framework and a tool selection guide for programme managers developed. Results: Authors reviewed tools used in urban immunisation contexts and tools designed for (i) non-immunization and/or non-health interventions in urban areas, and (ii) immunisation in rural contexts that had relevance for urban areas (e.g., Reaching every District/Child/ Zone). Many approaches combined several tools and methods, which authors categorised as diagnostic, programme, and intervention. The most common diagnostic tools were cross-sectional surveys, key informant interviews, focus group discussions, secondary analysis of routine data, and geographical mapping of outcomes, resources, and services. Programme tools involved multiple stages of data collection, analysis, insight generation, and intervention planning and included guidance documents from WHO (World Health Organisation), UNICEF (United Nations Children's Fund), USAID (United States Agency for International Development), and governments, and articles reporting on diagnostics, interventions, and/or evaluations to improve urban immunisation. Interventions involved service improvement, education, reminder/recall, incentives, outreach, mass-media, or were multi-component. The main gaps in existing tools were an assessment of macro/policy-level factors, exploration of effective immunization communication channels, and measuring in/out-migration. The proposed framework uses a problem tree approach to suggest tools to address five common challenges (i.e. identifying populations, understanding communities, issues with service access and use, improving services, improving coverage) based on context and available data. Conclusion: This study identified many tools relevant to evaluating urban LMIC immunisation programmes, including significant crossover between tools. This was encouraging in terms of supporting the identification of common areas, but problematic as data volumes, instructions, and activities could overwhelm managers and tools are not always suitably applied to suitable contexts. Further research is needed on how best to combine tools and methods to suit local contexts. Authors’ initial framework can be tested and developed further.

Keywords: health equity, immunisation, low and middle-income countries, poverty, urban health

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Authors: Claire Harrison, Raajit K. Rampal, Vikas Gupta, Srdan Verstovsek, Moshe Talpaz, Jean-Jacques Kiladjian, Ruben Mesa, Andrew Kuykendall, Alessandro Vannucchi, Francesca Palandri, Sebastian Grosicki, Timothy Devos, Eric Jourdan, Marielle J. Wondergem, Haifa Kathrin Al-Ali, Veronika Buxhofer-Ausch, Alberto Alvarez-Larrán, Sanjay Akhani, Rafael Muñoz-Carerras, Yury Sheykin, Gozde Colak, Morgan Harris, John Mascarenhas

Abstract:

Myelofibrosis (MF) is characterized by bone marrow fibrosis, anemia, splenomegaly and constitutional symptoms. Progressive bone marrow fibrosis results from aberrant megakaryopoeisis and expression of proinflammatory cytokines, both of which are heavily influenced by bromodomain and extraterminal domain (BET)-mediated gene regulation and lead to myeloproliferation and cytopenias. Pelabresib (CPI-0610) is an oral small-molecule investigational inhibitor of BET protein bromodomains currently being developed for the treatment of patients with MF. It is designed to downregulate BET target genes and modify nuclear factor kappa B (NF-κB) signaling. MANIFEST-2 was initiated based on data from Arm 3 of the ongoing Phase 2 MANIFEST study (NCT02158858), which is evaluating the combination of pelabresib and ruxolitinib in Janus kinase inhibitor (JAKi) treatment-naïve patients with MF. Primary endpoint analyses showed splenic and symptom responses in 68% and 56% of 84 enrolled patients, respectively. MANIFEST-2 (NCT04603495) is a global, Phase 3, randomized, double-blind, active-control study of pelabresib and ruxolitinib versus placebo and ruxolitinib in JAKi treatment-naïve patients with primary MF, post-polycythemia vera MF or post-essential thrombocythemia MF. The aim of this study is to evaluate the efficacy and safety of pelabresib in combination with ruxolitinib. Here we report updates from a recent protocol amendment. The MANIFEST-2 study schema is shown in Figure 1. Key eligibility criteria include a Dynamic International Prognostic Scoring System (DIPSS) score of Intermediate-1 or higher, platelet count ≥100 × 10^9/L, spleen volume ≥450 cc by computerized tomography or magnetic resonance imaging, ≥2 symptoms with an average score ≥3 or a Total Symptom Score (TSS) of ≥10 using the Myelofibrosis Symptom Assessment Form v4.0, peripheral blast count <5% and Eastern Cooperative Oncology Group performance status ≤2. Patient randomization will be stratified by DIPSS risk category (Intermediate-1 vs Intermediate-2 vs High), platelet count (>200 × 10^9/L vs 100–200 × 10^9/L) and spleen volume (≥1800 cm^3 vs <1800 cm^3). Double-blind treatment (pelabresib or matching placebo) will be administered once daily for 14 consecutive days, followed by a 7 day break, which is considered one cycle of treatment. Ruxolitinib will be administered twice daily for all 21 days of the cycle. The primary endpoint is SVR35 response (≥35% reduction in spleen volume from baseline) at Week 24, and the key secondary endpoint is TSS50 response (≥50% reduction in TSS from baseline) at Week 24. Other secondary endpoints include safety, pharmacokinetics, changes in bone marrow fibrosis, duration of SVR35 response, duration of TSS50 response, progression-free survival, overall survival, conversion from transfusion dependence to independence and rate of red blood cell transfusion for the first 24 weeks. Study recruitment is ongoing; 400 patients (200 per arm) from North America, Europe, Asia and Australia will be enrolled. The study opened for enrollment in November 2020. MANIFEST-2 was initiated based on data from the ongoing Phase 2 MANIFEST study with the aim of assessing the efficacy and safety of pelabresib and ruxolitinib in JAKi treatment-naïve patients with MF. MANIFEST-2 is currently open for enrollment.

Keywords: CPI-0610, JAKi treatment-naïve, MANIFEST-2, myelofibrosis, pelabresib

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