Search results for: patient autonomy

Authors: Nick Woodier, Paul Sampson, Iain Moppett

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Background: For years, healthcare across the world has recognised that patients are coming to harm from the very processes meant to help them. In response, healthcare tells itself that it needs to ‘be more like aviation.’ Aviation safety is highly regarded by those in healthcare and is seen as an exemplar. Specifically, healthcare is keen to learn from how aviation uses near misses to make their industry safer. Healthcare is rife with near misses; however, there has been little progress addressing them, with most research having focused on reporting. Addressing the factors that contribute to near misses will potentially help reduce the number of significant, harm patientsafety incidents. While the healthcare literature states the need to learn from aviation’s use of near misses, there is nothing that describes how best to do this. The authors, as part of a larger study of near-miss management in healthcare, sought to learn from aviation to develop principles for how healthcare can identify, report, and learn from near misses to improve patient safety. Methods: A Grounded Theory (GT) methodology, augmented by a scoping review, was used. Data collection included interviews, field notes, and the literature. The review protocol is accessible online. The GT aimed to develop theories about how aviation, amongst other safety-critical industries, manages near misses. Results: Twelve aviation interviews contributed to the GT across passenger airlines, air traffic control, and bodies involved in policy, regulation, and investigation. The scoping review identified 83 articles across a range of safety-critical industries, but only seven focused on aviation. The GT identified that aviation interprets the term ‘near miss’ in different ways, commonly using it to specifically refer to near-miss air collisions, also known as Airproxes. Other types of near misses exist, such as health and safety, but the reporting of these and the safety climate associated with them is not as mature. Safety culture in aviation was regularly discussed, with evidence that culture varies depending on which part of the industry is being considered (e.g., civil vs. business aviation). Near misses are seen as just one part of an extensive safety management system, but processes to support their reporting and their analysis are not consistent. Their value alone is also questionable, with the challenge to long-held beliefs originating from the ‘common cause hypothesis.’ Conclusions: There is learning that healthcare can take from how parts of aviation manage and learn from near misses. For example, healthcare would benefit from a formal safety management system that currently does not exist. However, it may not be as simple as ‘healthcare should learn from aviation’ due to variation in safety maturity across the industry. Healthcare needs to clarify how to incorporate near misses into learning and whether allocating resources to them is of value; it was heard that catastrophes have led to greater improvements in safety in aviation.

Keywords: aviation safety, patient safety, near miss, safety management systems

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Authors: Aguiar-Castillo Lidia, Perez-Jimenez Rafael

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The integration of gamification in educational settings aims to enhance student engagement and motivation through game design elements in learning activities. This paper introduces "Gamipulation," the subtle manipulation of students via gamification techniques serving hidden agendas without explicit consent. It highlights the need to distinguish between beneficial and exploitative uses of gamification in education, focusing on its potential to psychologically manipulate students for purposes misaligned with their best interests. Through a literature review and expert interviews, this study presents a conceptual framework outlining gamipulation's features. It examines ethical concerns like gradually introducing desired behaviors, using distraction to divert attention from significant learning objectives, immediacy of rewards fostering short-term engagement over long-term learning, infantilization of students, and exploitation of emotional responses over reflective thinking. Additionally, it discusses ethical issues in collecting and utilizing student data within gamified environments.  Key findings suggest that while gamification can enhance motivation and engagement, there's a fine line between ethical motivation and unethical manipulation. The study emphasizes the importance of transparency, respect for student autonomy, and alignment with educational values in gamified systems. It calls for educators and designers to be aware of gamification's manipulative potential and strive for ethical implementation that benefits students. In conclusion, this paper provides a framework for educators and researchers to understand and address gamipulation's ethical challenges. It encourages developing ethical guidelines and practices to ensure gamification in education remains a tool for positive engagement and learning rather than covert manipulation.

Keywords: gradualness, distraction, immediacy, infantilization, emotion

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Authors: Hussain Ali, Ahmad Ali, Syed Rashid Ali

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The maternal mortality is one of the basic health issues faced by rural women in Pakistan. There are various structural and socio-cultural determinants which confine women to domestic sphere. Such mobility restriction compels women for home delivery which causes high maternal mortality and morbidity. However, it is hard to find out the research findings and well-organized literature that explain the cultural factors act as determinant to home delivery among Pakhtun women. The overall objective of this research is to study men’s decision making within the household in Pakhtun society as determinant of home delivery among Pakhtun women in Khyber Pakhtunkhwa province of Pakistan. In the present study, researchers used the quantitative research design in which the data are collected through household survey technique from (n=503) ever-married women having reproductive age (15-49 years) by using interview schedule. The data are analyzed through SPSS, and binary logistic regression was applied to draw the association between home as a place of delivery and men’s decision making in the Pakhtun society. The results show that majority (76%) of the husbands are key decision makers about the home delivery due to their superior position within household. Similarly, majority (88%) Pakhtun women prefer to stay in home for their delivery due to their dependency on husband’s decision. The researcher concludes that men are key decision makers in Pakhtun society and their decisions affect women maternal health care. Similarly, the women are in subordinate position, and their limited decision making in the domestic sphere are greatly responsible for home delivery which causing high maternal mortality rate in the study area. In order to achieve Sustainable Development Goal No. 3, the study recommends empowering women in the decision making about accessing and utilizing maternal health care services and given financial autonomy to them.

Keywords: home delivery, men’s decision, Pakhtun women, subordinate position

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Authors: Jeewantha Ranawaka, Gunawardane Kapila, Wijethunaga Mudiyanselage B. G. Jayathilake

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Introduction: Sweeping of the membranes is a fairly simple technique that may positively influence the shift from maintenance of pregnancy to the beginning of labor. Objective: To assess the effectiveness and acceptability of twice versus once-only membrane sweeping in uncomplicated primi gravid at 40 weeks of gestational age in a tertiary care hospital in Sri Lanka. Methods: A randomized controlled clinical trial was done in Ward 05 of Teaching Hospital, Kandy. The participants were primi-gravida with a singleton live fetus who was at 40 weeks of gestation with intact fetal membranes and with a Modified Bishop’s score <5. After randomization both groups received membrane sweeping at 40 weeks of gestation and the experimental group received membrane sweeping after 48 hours (40+2 days). The modified Bishop Score was assessed at 40+5 days. In two groups who did not go into natural labor at 40+5 days were managed according to the ward policy of cervical ripening and with labor induction at 40+5 days. Two different methods were used to assess discomfort and pain. Patient acceptability was assessed using recommendation to another patient and acceptance during next pregnancy. Perinatal, maternal and labour outcomes were assessed. Results: A change of the Bishops score was 67.3% (n= 31 of 46) in experimental group whereas in control group it was 57.5% (n= 38 of 66). (p = 0.21, OR-1.52, CI = 0.6 -3.34). Mean (SD) of Modified Bishop score was 6.36 (1.94) in experimental group and 6.03 (.84) in control group (p = 0.354). The probability of having the spontaneous onset of labour in experimental group was 61.6% (n=74 of 120) whereas in control group it was 45% (n= 54 of 120) (p=0.01, OR-1.966, CI = 1.17 – 3.28 NNT = 5.99). Recommending the method to another among experimental group was 75% (n= 90 of 120) whereas in control group it was 79.2% (n= 95 of 120) (p= 0.443). Accepting membrane Sweeping for subsequent pregnancy among experimental was 72.5% (n=87 of 120) whereas in control group was 72.5% (n=87 of 120) (p= 1.00) Need of formal induction of labour at 40+ 5 days in experimental group was 38.4% (n=46 of 120) whereas in control group was 61.6% (n=66 of 120) (p=0.01, OR=0.5, CI= 0.3 – 0.8, NNT=6). Neonatal outcome, labour outcome such as Cesarean -section rate, need for augmentation and maternal complications such as fever, Premature rupture of membrane, bleeding were comparable in two groups. Conclusions and Recommendations: It can be concluded that twice sweeping of membrane was effective to reduce the need of formal induction of labour and increase the chances of having spontaneous onset of labour (SOL) at 40+5 days without increasing maternal or fetal morbidity. Acceptability of twice sweeping is not different from sweeping once. Hence we recommend consideration of multiple membranes sweeping as first line for women at 40 weeks of gestation.

Keywords: acceptability, induction, labour, membrane sweeping

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Authors: Subramanyam Devarakonda Hanumantharao, Udayendu Prakash Sharma, Mahesh Garg

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Introduction: Gomabai Netralaya a reputed eye hospital is located in Neemuch a small city of Madhya Pradesh, India. The hospital is established in 1992 by Late. G.D Agrawal a renowned educationist, freedom fighter and philanthropist. The eye hospital was established to serve all sections of the society in affordable manner. To provide comprehensive eye care services to the rural poor the hospital started organizing outreach camps since 1994. Purpose: To study the cost effectiveness of outreach eye camps for addressing the sustainability issues of the outreach program. Methods: One year statistics of outreach eye camps were collected from Hospital Management Information System software to analyze the productivity of camps. Income and expenses report was collected from outreach department records to analyze per camp expenses and per patient expenses against the income generated. All current year records were analyzed to have accuracy of information and results. Information was collected in two ways: 1)Actual camp performance records and expenses from book of accounts. 2)Cross verification was done through one to one discussion with outreach staff. Results: Total 17534 outpatients were examined through 52 outreach eye camps. Total 6042 (34% of total outpatients) patients were advised with cataracts and 4651 (77% of advice) operations were performed. The average OPD per camp was 337 and per camp 116 patients was advised for cataract surgery and 89 surgeries were performed per camp. Total 18200 US$ incurred on organizing 52 outreach camps in the radius of 100 k.ms. Considering the total outpatients screened through camps the screening cost per patient was 1.00 US$ and considering the surgical output the per surgery expenses was 4.00 US$. The cost recovery of the total expenses was through Government grant of US$ 16.00 per surgery (that includes surgical grant). All logistics cost of camps and patients transportation cost was taken care by local donors. Conclusion: The present study demonstrates that with people’s participation, successful high volume outreach eye camps can be organized. The cost effectiveness of the outreach camps is totally depended on volume of outpatient’s turn-up at camp site and per camp surgical output. The only solution to sustainability of outreach eye camps is sharing of cost with local donors and increasing productivity.

Keywords: camps, outreach, productivity, sustainable

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Authors: Christine Y. Yeh, Brian D. Piening, Sarah M. Totten, Kimberly Kukurba, Wenyu Zhou, Kevin P. F. Contrepois, Gucci J. Gu, Sharon Pitteri, Michael Snyder

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Three million deaths worldwide are attributed to obesity. However, the biomolecular mechanisms that describe the link between adiposity and subsequent disease states are poorly understood. Insulin resistance characterizes approximately half of obese individuals and is a major cause of obesity-mediated diseases such as Type II diabetes, hypertension and other cardiovascular diseases. This study makes use of longitudinal quantitative and high-throughput multi-omics (genomics, epigenomics, transcriptomics, glycoproteomics etc.) methodologies on blood samples to develop multigenic and multi-analyte signatures associated with weight gain and insulin resistance. Participants of this study underwent a 30-day period of weight gain via excessive caloric intake followed by a 60-day period of restricted dieting and return to baseline weight. Blood samples were taken at three different time points per patient: baseline, peak-weight and post weight loss. Patients were characterized as either insulin resistant (IR) or insulin sensitive (IS) before having their samples processed via longitudinal multi-omic technologies. This comparative study revealed a wealth of biomolecular changes associated with weight gain after using methods in machine learning, clustering, network analysis etc. Pathways of interest included those involved in lipid remodeling, acute inflammatory response and glucose metabolism. Some of these biomolecules returned to baseline levels as the patient returned to normal weight whilst some remained elevated. IR patients exhibited key differences in inflammatory response regulation in comparison to IS patients at all time points. These signatures suggest differential metabolism and inflammatory pathways between IR and IS patients. Biomolecular differences associated with weight gain and insulin resistance were identified on various levels: in gene expression, epigenetic change, transcriptional regulation and glycosylation. This study was not only able to contribute to new biology that could be of use in preventing or predicting obesity-mediated diseases, but also matured novel biomedical informatics technologies to produce and process data on many comprehensive omics levels.

Keywords: insulin resistance, multi-omics, next generation sequencing, proteogenomics, type ii diabetes

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Authors: Rashid Azeem

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Introduction: Eosinophilia, which can be categorized as mild, moderate, and severe form on the basis of increasing eosinophil counts, might be responsible for a wide range of cardiac manifestations, varying from a simple myocarditis to a severe state like endomyocardial fibrosis. Eosinophils are involved in the pathogenesis of a variety of cardiovascular disorder like Loffler endocarditis, eosinophilic granulomatosis with polyangitis (EGPH), and hyper eosinophilic (HES). Among them HES carries and incidence rate b/w 48% and 75% and is the main causes of cardiac motility and mobility due to eosinophilia involvement. Aims and objectives: The aim of this study is to determine the frequency of eosinophilia in cardiac patients and to ascertain the evidence of endomyocardial diseases in eosinophilic patients in a cardiology institution Material and Methods: This cross sectional analytical study was conducted in hematology Department of Peshawar institute of Cardiology after approval from hospital ethical and research committee. All 70 patients were subjected to detailed history and clinical examination. Investigation like CBC, Chest X-ray, ECG, Echo, Angiography findings were used to monitor patient’s clinical status. Data is analyzed using SPSS version 25 and MS Excel. Results: Out of 70 patients in our study, a total of 66 patients(94 %) shows evidence of cardiac manifestations. In our study, we have observed a number of abnormal ECG patterns in cardiac patients presenting with eosinophilia, like T wave changes, loss of R wave, sinus bradycardia with LVH strain, and ST wave abnormality. abnormal echocardiographic findings were observed in our patients, like valvular abnormalities (in 45.7%), RWMA abnormalities (in 2.8%), isolated ventricular dysfunction (in 21.4%), and in 10% patients, normal echocardiography. We further noted abnormal coronary angiography findings in cardiac patients with eosinophilia ranging from single vessel to multi vessel occlusions. Conclusions: Eosinophils are involved in the pathogenesis of a variety of cardiovascular disorders which can be detected by various diagnostic means, and the severity of the disease increases with time and with increasing eosinophil count ranging from simple myocarditis to a fatal condition like endomyocardial fibrosis. Thus, increased eosinophilic count as a laboratory parameter in cardiac patients may be a sign of endomyocardial damage which will further help cardiologist to intervene more aggressively then routine approach to a cardiac patient.

Keywords: eosinophilia, endomyocardial fibrosis, cardiac, hypereosinophilic syndrome

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Authors: Stefano A. Denes, Riccardo Tieghi, Giovanni Elia

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The buccal fat pad is a well-established tool in oral and maxillofacial surgery and its use has proved of value for the closure of oroantral communications. Oroantral communication may be a common complication after sequestrectomy in "Bisphosphonate-related osteonecrosis of the jaws". We report a clinical case of a 70-year-old female patient in bisphosphonate therapy presented with right maxillary sinusitis and oroantral communication after implants insertion. The buccal fat pad was used to close the defect. The case had an uneventful postoperative healing without dehiscence, infection and necrosis. We postulate that the primary closure of the site with buccal fat pad may ensure a sufficient blood supply and adequate protection for an effective bone-healing response to occur.

Keywords: buccal fat pad, oroantral communication, oral surgery, dehiscence

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Authors: Uzma Imtiaz

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Ecological feminism adheres to the basic philosophy that patriarchy is the wellspring of natural and gender domination. It explores the relationship between women and nature in a patriarchal society. Eco-feminism argues that women and nature have an intrinsic association and exploitation of women is the exploitation of nature itself. It further views the world as a holistic institution that offers equal opportunities for men and women. Eco-feminism rejects male domination in a patriarchal society where men and women do not get equal rights to survival. Furthermore, it investigates modern capitalist practices that exert unjust male dominance over nature and women. Cultural eco-feminist theorists argue that industrialization and modern science are male-centered and exhibit male chauvinistic views in attempts to control females’ ability to reproduce. This research intends to analyze an eco-feminist novel by Laila Halaby from the eco-feminism theoretical framework of Maria Mies and Vandana Shiva. The feminist dystopian novel throws light on the double-faced processes of capitalism and housewifization that destroy the autonomy of women over their bodies and life. Moreover, this study aims to highlight the unjust capitalistic processes and policies that turn other countries and women into colonies to exploit them by white men in the name of progress and civilization. The novel brings the patriarchal ways of dominance over women into question. This research paper concludes that women and men should get equal opportunities to survive in society, and women should have given rights over their bodies to decide their future. The research is qualitative in nature, so the method of close reading is selected to analyze the hypodermic effect of patriarchy in society. This study is valuable in highlighting the exploitative ways of men to subjugate women and nature and helps to give awareness to women against gender exploitation in society.

Keywords: housewifization, exploitation, capitalist patriarchy, female victimization

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Authors: Rupinder Kaler, Faith Ndebele, Nadia Saleem, Hafsa Sheikh

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Background: Workplace related violence and aggression seems to be considered an acceptable occupational hazard for staff in mental health services. There is literature evidence that healthcare workers in mental health settings are at higher risk from aggression from patients. Aggressive behaviours pose a physical and psychological threat to the psychiatric staff and can result in stress, burnout, sickness, and exhaustion. Further evidence informs that health professionals are the most exposed to psychological disorders such as anxiety, depression and post-traumatic stress disorder. Fear that results from working in a dangerous environment and exhaustion can have a damaging impact on patient care and healthcare relationship. Aim: The aim of this study is to investigate the prevalence and impact of aggressive behaviour on staff working at Coventry and Warwickshire Partnership Trust. Methodology: The study methodology included carrying out a manual, anonymised, multi-disciplinary cross-sectional survey questionnaire across all clinical and non-clinical staff at CWPT from both inpatient and community settings. Findings: The unsurprising finding was that of higher prevalence of aggressive behaviours in in-patients in comparison to community staff. Conclusion: There is a high rate of verbal and physical aggression at work and this has a negative impact on the staff emotional and physical well- being. There is also a higher reliance on colleagues for support on an informal basis than formal organisational support systems. Recommendations: A workforce that is well and functioning is the biggest resource for an organisation. Staff safety during working hours is everyone's responsibility and sits with both individual staff members and the organisation. Post-incident organisational support needs to be consolidated, and hands-on, timely support offered to help maintain emotionally well staff on CWPT. The authors recommend development of preventative and practical protocols for aggression with patient and carer involvement. Post-incident organisational support needs to be consolidated, and hands-on, timely support offered to help maintain emotionally well staff on CWPT.

Keywords: safer staff, survey of staff experiences, violence and aggression, mental health

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Authors: Irena Balaban Cakirpaloglu, Karla Hrbackova

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This paper focuses on the issue of intercultural competencies of university students who are preparing to work in assisting professions. In recent years, the Czech Republic has become a major destination for many people from different cultural environments, and there is a growing need for workers in assisting professions to be able to respond flexibly and adequately to the changing living conditions of multicultural coexistence. The main objective of this study is to analyse the preparedness of students in assisting professions in relation to intercultural competencies. Intercultural competences include several essential skills for working successfully with diversity. Taking into account the main objective of this research, a pilot study was conducted among students of Social Pedagogy at the Faculty of Humanities at Tomas Bata University in Zlin in the academic year 2017/2018. The research sample consisted of 116 students. To obtain the data, we used the Cross-Cultural Adaptability Inventory (CCAI) by Kelley and Meyers. The inventory maps strengths and weaknesses in 4 skill areas: Emotional Resilience, Flexibility/Openness, Perceptual Acuity and Personal Autonomy. This inventory also examines individual ability to succeed in intercultural interaction and communication. The results obtained from the survey were statistically processed and analysed using the relevant statistical methods. The results of the survey point to the fact that students of social pedagogy achieve average to below average results in individual skill areas. At the same time, significant differences have been detected among the students with work experience in multicultural environment and those with no experience.

Keywords: cross–cultural adaptability inventory, diversity, intercultural competences, students of social pedagogy

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Authors: Robin Singh, Jing-Chiou Liou

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The Internet of Things (IoT) devices are being used heavily as part of our everyday routines. Through improved communication and automated procedures, its popularity has assisted users in raising the quality of work. These devices are used in healthcare in order to better collect the patient’s data for their treatment. They are generally considered safe and secure. However, there is some possibility that some loopholes do exist which manufacturers do need to identify before some hacker takes advantage of them. For this study, we focused on two medical IoT devices which are pacemakers and hearing aids. The aim of this paper is to identify if there is any likelihood of these medical devices being hijacked and used as a botnet in Distributed Denial-Of Service attacks. Moreover, some mitigation strategies are being proposed to better secure

Keywords: cybersecurity, DDoS, IoT, medical devices

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Authors: Adeline Fontvieille, Hugo Parent-Roberge, Marie-France Langlois, Tamas Fulop, Michel Pavic, Eleonor Riesco

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Introduction: Total lean body mass is reduced during cancer treatment. This loss is called cancer cachexia and is accompanied by a progressive loss of fat mass. In older adults, these body composition changes can have a larger impact on metabolic health, physical autonomy, and cancer survival. Although currently untreatable, exercise training could reduce these effects. Hence, the objective of this pilot study is to investigate if 12 weeks of exercise training during cancer treatment can mitigate the loss of muscle mass and fat mass in older adults. Methods: A total of 40 older adults (65-80 years) with an ongoing treatment for a curable cancer are currently recruited and randomised in two groups: 1) Combined training (EX, n=20) and 2) Control group (CON, n=20). All variables are measured before and after 12 weeks of intervention: Anthropometry (weight, height, body mass index), body composition (total fat mass, visceral adipose tissue, total and appendicular muscle mass; DXA), metabolic profile (HDL-C and LDL-C, triglycerides, glucose and insulin levels). Results: Preliminary analyses revealed no impact of exercise training on appendicular muscle mass (p=0,31) and fat mass (p=0,31). Furthermore, total body weight, waist circumference, HDL-cholesterol, LDL-cholesterol, glucose and insulin levels remained unchanged (all p ≥ 0.79) after 12 weeks of training. However, statistical analyses revealed that triglyceride levels slightly increased (p=0.03), irrespective of the group. Conclusion: Preliminary analyses did not reveal any impact of aerobic and resistance exercise training on body composition in oncogeriatric patients. Furthermore, exercise training seems not efficient to prevent the cancer treatment-related triglyceride levels increase.

Keywords: muscle mass, fat mass, metabolic profile, combined training, aging, cancer

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Authors: Rosa Tsegaye Aga, Xuan Jiang, Pavel Vazquez Faci, Siqing Liu, Simon Rayner, Endalkachew Alemu, Markos Abebe

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Tuberculosis (TB) is a major cause of disease globally. In most cases, TB is treatable and curable, but only with the proper treatment. There is a time when drug-resistant TB occurs when bacteria become resistant to the drugs that are used to treat TB. Current strategies to identify drug-resistant TB bacteria are laboratory-based, and it takes a longer time to identify the drug-resistant bacteria and treat the patient accordingly. But machine learning (ML) and data science approaches can offer new approaches to the problem. In this study, we propose to develop an ML-based model to predict the antibiotic resistance phenotypes of TB isolates in minutes and give the right treatment to the patient immediately. The study has been using the whole genome sequence (WGS) of TB isolates as training data that have been extracted from the NCBI repository and contain different countries’ samples to build the ML models. The reason that different countries’ samples have been included is to generalize the large group of TB isolates from different regions in the world. This supports the model to train different behaviors of the TB bacteria and makes the model robust. The model training has been considering three pieces of information that have been extracted from the WGS data to train the model. These are all variants that have been found within the candidate genes (F1), predetermined resistance-associated variants (F2), and only resistance-associated gene information for the particular drug. Two major datasets have been constructed using these three information. F1 and F2 information have been considered as two independent datasets, and the third information is used as a class to label the two datasets. Five machine learning algorithms have been considered to train the model. These are Support Vector Machine (SVM), Random forest (RF), Logistic regression (LR), Gradient Boosting, and Ada boost algorithms. The models have been trained on the datasets F1, F2, and F1F2 that is the F1 and the F2 dataset merged. Additionally, an ensemble approach has been used to train the model. The ensemble approach has been considered to run F1 and F2 datasets on gradient boosting algorithm and use the output as one dataset that is called F1F2 ensemble dataset and train a model using this dataset on the five algorithms. As the experiment shows, the ensemble approach model that has been trained on the Gradient Boosting algorithm outperformed the rest of the models. In conclusion, this study suggests the ensemble approach, that is, the RF + Gradient boosting model, to predict the antibiotic resistance phenotypes of TB isolates by outperforming the rest of the models.

Keywords: machine learning, MTB, WGS, drug resistant TB

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Authors: Yong H Sheng, Beatriz Garcillán, Eden Whitlock, Yukli Freedman, SiLing Yang, M Arifur Rahman, Nicholas Weber, Fabienne Mackay

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Chronic lymphocytic leukemia (CLL) is closely associated with immune dysfunction, yet the mechanisms underlying this immune deficiency remain poorly understood. Transmembrane Activator and CAML Interactor (TACI), a receptor known for its role in IL-10 regulation and autoimmunity, to the best of our knowledge has not been investigated in the context of anti-tumor immunity or its impact on CLL progression. This study addresses the gap by exploring the role of TACI in regulating CLL cells within the tumor microenvironment and its broader effects on disease progression and immune competence. We utilized the Eµ-TCL1 mouse model to generate CLL mice deficient in TACI and examined the consequences of TACI loss in adoptive transfer models over a five-week period. Comprehensive transcriptomic analysis, including RNA sequencing and microarray, was employed to determine TACI’s influence on the CLL gene expression profile. Additionally, we studied TACI’s direct role in CLL cell migration and immune modulation using patient-derived CLL cells in culture and Patient-Derived Xenograph (PDX) models. Our findings demonstrate that TACI signaling plays a pivotal role in promoting CLL progression and immune suppression. Loss of TACI signaling significantly inhibited CLL development and enhanced immune functionality. When TACI+/+ or TACI-/- TCL1 CLL cells were transferred into wild-type recipient mice, those receiving TACI-deficient cells showed reduced disease progression and lower incidence of CLL. Mice with TACI-/- CLL cells exhibited normalized serum levels of pro-inflammatory cytokines IL-6 and IL-10, restored proportions of T-cell subsets, and improved immune compartment function compared to counterparts with TACI+/+ CLL cells. Mechanistically, TACI-deficient CLL cells expressed significantly lower levels of IL-10, TNF, and inhibitory receptors such as PD-L1 and PD-L2. These cells also display restored circulating immunoglobulin levels and responses to T cell-dependent antigens, highlighting a recovery of immune competence. Further mechanistic studies revealed that TACI signaling drives CLL cell migration and homing to the spleen, where these cells actively establish an immunosuppressive microenvironment that supports immune evasion and tumor growth. Patient-derived CLL cells and PDX models confirmed TACI’s direct role in enhancing CLL cell migration and fostering immune suppression, emphasizing its critical function in the tumor microenvironment. By disrupting TACI signaling, we observed a reduction in CLL-associated immune suppression and tumor progression, offering a promising therapeutic avenue. This study establishes, for the first time, that targeting TACI disrupts key mechanisms underlying CLL progression while preserving vital immune functions. Unlike existing treatments that often impair immunity and lead to infection-related complications, TACI inhibition offers the dual benefit of controlling disease and maintaining immune homeostasis. These findings provide a strong rationale for developing therapeutic strategies that inhibit TACI as a means to improve outcomes in CLL patients. Beyond its implications for CLL, this research underscores the broader importance of TACI in regulating immune-tumor interactions, paving the way for future studies into its role in other malignancies.

Keywords: chronic lymphocytic leukemia, TACI, IL-10, immune suppression

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Authors: Euripides Antoniades

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In 1821, the Greek Revolution movement, under the political influence that arose from the French revolution, and the corresponding movements in Italy, Germany and America, demanded the liberation of the nation and the establishment of an independent national state. Published topics in the British press regarding the Greek Revolution, focused on: a)the right of the Greeks to claim their freedom from Turkish domination in order to establish an independent state based on the principle of national autonomy, b)criticism regarding Turkish rule as illegal and the power of the Ottoman Sultan as arbitrary, c)the recognition of the Greek identity and its distinction from the Turkish one and d)the endorsement Greeks as the descendants of ancient Greeks. The London Times is a print publication that presents, in chronological or thematic order, the news, opinions or announcements about the most important events that have occurred in a place during a specified period of time. A combination of qualitative and quantitative content analysis was applied. An attempt was made to record Greek Revolution references along with the usage of specific words and expressions that contribute to the representation of the historical events and their exposure to the reading public. Key finds of this research reveal that a)there was a frequency of passionate daily articles concerning the events in Greece, their length, and context in The Times of London, b)he British public opinion was influenced by this particular newspaper and c) he newspaper published various news about the revolution by adopting the role of animator of the Greek struggle. In fact, this type of news was the main substance of the The London Times’ structure, establishing a positive image about the Greek Revolution contributing to the European diplomatic development. These factors offered a change in the attitude of the British and Russians respectively assuming a positive approach towards Greece.

Keywords: Greece, revolution, press, the london times, great britain, mass media

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Authors: Suat Erel, Gozde Gur

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Background: Recently a supramalleolar type of dynamic ankle foot orthosis (DAFO) has been increasingly used to support all of the dynamic arches of the foot and redistribute the pressure under the plantar surface of the foot to reduce the muscle tone. DAFO helps to maintain balance and postural control by providing stability and proprioceptive feedback in children with disease like Cerebral Palsy, Muscular Dystrophies, Down syndrome, and congenital hypotonia. Aim: The aim of this study was to investigate the role of Dynamic ankle foot orthosis (DAFO) on temporo-spatial parameters of gait and balance in three children with hereditary spastic paraparesis (HSP). Material Method: 13, 14, and 8 years old three children with HSP were included in the study. To provide correction on weight bearing and to improve gait, DAFO was made. Lower extremity spasticity (including gastocnemius, hamstrings and hip adductor muscles) using modified Ashworth Scale (MAS) (0-5), The temporo-spatial gait parameters (walking speed, cadence, base of support, step length) and Timed Up & Go test (TUG) were evaluated. All of the assessments about gait were compared with (with DAFO and shoes) and without DAFO (with shoes only) situations. Also after six months follow up period, assessments were repeated by the same physical therapist. Results: MAS scores for lower extremity were between “2-3” for the first child, “0-2” for the second child and “1-2” for the third child. TUG scores (sec) decreased from 20.2 to 18 for case one, from 9.4 to 9 for case two and from 12,4 to 12 for case three in the condition with shoes only and also from 15,2 to 14 for case one, from 7,2 to 7,1 for case two and from 10 to 7,3 for case three in the condition with DAFO and shoes. Gait speed (m/sec) while wearing shoes only was similar but while wearing DAFO and shoes increased from 0,4 to 0,5 for case one, from 1,5 to 1,6 for case two and from 1,0 to 1,2 for case three. Base of support scores (cm) wearing shoes only decreased from 18,5 to 14 for case one, from 13 to 12 for case three and were similar as 11 for case two. While wearing DAFO and shoes, base of support decreased from 10 to 9 for case one, from 11,5 to 10 for case three and was similar as 8 for case two. Conclusion: The use of a DAFO in a patient with HSP normalized the temporo-spatial gait parameters and improved balance. Walking speed is a gold standard for evaluating gait quality. With the use of DAFO, walking speed increased in this three children with HSP. With DAFO, better TUG scores shows that functional ambulation improved. Reduction in base of support and more symmetrical step lengths with DAFO indicated better balance. These encouraging results warrant further study on wider series.

Keywords: dynamic ankle foot orthosis, gait, hereditary spastic paraparesis, balance in patient

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Authors: Amber Lim, Ted Ruffman

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A vast amount of research evidence indicates that children develop social attitudes that are similar to those of their parents. When using general measures of social attitudes, such as social dominance orientation (SDO), right-wing authoritarianism (RWA), and prejudice, studies show that parents' and children’s attitudes were correlated. However, the mechanisms behind the intergenerational transmission of attitudes remain largely unexplained. Since it was speculated that the origins of RWA could be traced back to one’s relationship with their parents, the aim of this study was to assess how parents’ social attitudes and parenting behavior are related to children’s social development. One line of research suggests that the different ways in which authoritarian and authoritative parents reason with their children may impact Theory of Mind (ToM) development. That is, inductive discipline (e.g., emphasising how the child’s actions affect others) facilitates empathy and ToM development. Conversely, past evidence shows that children have poorer ToM development when parents enforce rules without explanation. Thus, this study addresses the question of how parent behavior plays a role in the gradual acquisition of a ToM and social attitudes. Seventy parents reported their social attitudes, parenting behavior, and their child’s mental state and non-mental state vocabulary. Their children were given ToM and perspective-taking tasks, along with a friend choice task to measure racial bias and anti-fat bias. As hypothesised, parents’ use of inductive reasoning correlated with children’s performance on Theory of Mind tasks. Mothers’ inductive reasoning facilitated children’s acquisition of mental state vocabulary. Parents’ autonomy granting was associated with improved mental state vocabulary. Authoritarian parenting traits such as verbal hostility were linked to children’s racial bias. These findings highlight the importance of parent-child discussion in shaping children’s social understanding.

Keywords: parenting style, prejudice, social attitudes, social understanding, theory of mind

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Authors: Hakan Duger, Alparslan Ersoy, Canan Ersoy

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Diabetes mellitus is the most common etiology of end-stage renal disease (ESRD). Also, diabetic nephropathy is the etiology of ESRD in approximately 23% of kidney transplant recipients. A successful kidney transplant improves the quality of life and reduces the mortality risk for most patients. However, patients require close follow-up after transplantation due to medical complications. Diabetes mellitus can affect patient morbidity and mortality due to possible effects of immunosuppressive therapy on glucose metabolism. We compared the frequency of medical complications and the outcomes in diabetic and non-diabetic kidney transplant recipients. Materials and Methods: This retrospective study conducted in 498 patients who underwent kidney transplant surgery at our center in 10-year periods. The patients were divided into two groups: diabetics (46 ± 10 year, 26 males, 16 females) and non-diabetics (39 ± 12 year, 259 males, 197 females). The medical complications, graft functions, causes of graft loss and death were obtained from medical records. Results: There was no significant difference between recipient age, duration of dialysis, body mass index, gender, donor type, donor age, dialysis type, histories of HBV, HCV and coronary artery disease between two groups. The history of hypertension in diabetics was higher (69% vs. 36%, p < 0.001). The ratios of hypertension (50.1% vs. 57.1%), pneumonia (21.9% vs. 20%), urinary infection (16.9% vs. 20%), transaminase elevation (11.5% vs. 20%), hyperpotasemia (14.7% vs. 17.1%), hyponatremia (9.7% vs. 20%), hypotension (7.1% vs. 7.9%), hypocalcemia (1.4% vs. 0%), thrombocytopenia (8.6% vs. 8.6%), hypoglycemia (0.7% vs. 0%) and neutropenia (1.8% vs. 0%) were comparable in non-diabetic and diabetic groups, respectively. The frequency of hyperglycaemia in diabetics was higher (8.6% vs. 54.3%, p < 0.001). After transplantation, primary non-function (3.4% vs. 2.6%), delayed graft function (25.1% vs. 34.2%) and acute rejection (7.3% vs. 10.5%) ratios of in non-diabetic and diabetic groups were similar, respectively. Hospitalization durations in non-diabetics and diabetics were 22.5 ± 17.5 and 18.7 ± 13 day (p=0.094). Mean serum creatinine levels in non-diabetics and diabetics were 1.54 ± 0.74 and 1.52 ± 0.62 mg/dL at 6th month. Forty patients had graft loss. The ratios of graft loss and death in non-diabetic and diabetic groups were 8.2% vs. 7.1% and 7.1% vs. 2.6% (p > 0.05). There was no significant relationship between graft and patient survivals with the development of medical complication. Conclusion: As a result, medical complications are common in the early period. Hyperglycaemia was frequently seen following transplantation due to the effects of immunosuppressant regimens. However, the frequency of other medical complications in diabetic patients did not differ from non-diabetic one. The most important cause of death is still infections. The development of medical complications during the first 6 months did not significantly affect transplant outcomes.

Keywords: kidney transplantation, diabetes mellitus, complication, graft function

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Authors: Aneri Mehta, Krunal Mehta

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Financial administration is part of government which deals with collection, preservation and distribution of public funds, with the coordination of public revenue and expenditure, with the management of credit operation on behalf of the state and with the general control of the financial affairs of public households. The researcher has taken the prime body of the local self government viz. Municipal Corporation. However, the number of municipal corporations in India has rapidly increased in recent years. Countries 27% of the total population are living in urban area & in recent it increasing very fast. People are moving very fast from rural area to urban area. Their demand, awareness is increasing day by day. The Municipal Corporations render many services for the development of the urban area. Thus, researcher has taken a step to know the accounting practices of the municipal corporations of Gujarat state (AMC & BMC ). The research will try to show you the status of finance of municipal corporations. Article 243(w) of the constitution of India envisaged that the state government maybe, by law , endow the municipalities with such powers and authorities as may be necessary to enable them to function as institution of self government and such law may contain provision for devolution of powers and responsibilities upon municipalities subjects to such condition as may be specified there in with respect to (i) the peroration of plans for economic development and social justice and (ii) the performance of the function and the implementation of schemes as may be entrusted to them including those in relation to the matters listed in the twelfth schedule. The three tier structure of the Indian Government i.e. Union, State & Local Self Government is the scenario of the Indian constitution. Local Self Government performs or renders many services under the direct control of state government. They (local bodies) possess autonomy within its limited sphere, raise revenue through local taxation and spend its income on local services.

Keywords: financial administration, urban local bodies, local self government, constitution

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Authors: W. Hajuthman, R. Warner, S. Rahman, M. Abraham, H. Helliwell, D. Bodiwala

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Context: Prostate cancer is a prevalent cancer in males in Europe and the US, with diagnosis primarily relying on PSA testing, mpMRI, and subsequent biopsies. However, this diagnostic strategy may lead to complications for patients. Research Aim: The aim of this study is to assess compliance with trust guidelines for antibiotic prophylaxis in patients undergoing transperineal template biopsies of the prostate and evaluate the rate of post-procedure complications. Methodology: This study is conducted retrospectively over an 8-month period. Data collection includes patient demographics, compliance with trust guidelines, associated risk factors, and post-procedure complications such as infection, haematuria, and urinary retention. Findings: The audit includes 100 patients with a median age of 66.11. The compliance with pre-procedure antibiotics was 98%, while compliance with antibiotic prophylaxis recommended by trust guidelines was 68%. Among the patients, 3% developed post-procedure sepsis, with 2 requiring admission for intravenous antibiotics. No evident risk factors were identified in these cases. Additionally, post-procedure urinary retention occurred in 3% of patients and post-procedure haematuria in 2%. Theoretical Importance: This study highlights the increasing use of transperineal template biopsies across UK centres and suggests that having a standardized protocol and compliance with guidelines can reduce confusion, ensure appropriate administration of antibiotics, and mitigate post-procedure complications. Data Collection and Analysis Procedures: Data for this study is collected retrospectively, involving the extraction and analysis of relevant information from patient records over the specified 8-month period. Question Addressed: This study addresses the following research questions: (1) What is the compliance rate with trust guidelines for antibiotic prophylaxis in transperineal template biopsies of the prostate? (2) What is the rate of post-procedure complications, such as infection, haematuria, and urinary retention? Conclusion: Transperineal template biopsies are becoming increasingly prevalent in the UK. Implementing a standardized protocol and ensuring compliance with guidelines can reduce confusion, ensure proper administration of antibiotics, and potentially minimize post-procedure complications. Additionally, considering that studies show no difference in outcomes when prophylactic antibiotics are not used, the reminder to follow trust guidelines may prompt a re-evaluation of antibiotic prescribing practices.

Keywords: prostate, transperineal template biopsies of prostate, antibiotics, complications, microbiology, guidelines

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Authors: Sultan Çağırıcı, Arsida Bajrami, Beyza Aslan, Hacı Ali Erdoğan, Nejla Sözer Topçular, Dilek Bozkurt, Vildan Yayla

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Objective: Corticobasal syndrome (CBS) is phenotypically characterized by asymmetric rigidity, apraxia, alien-limb phenomenon, cortical sensory loss, dystonia and myoclonus. The underlying pathologies consists of corticobasal degeneration (CBD), progressive supra nuclear palsy, Alzheimer's, Creutzfeldt-Jakob and frontotemporal degeneration. CBD is a degenerative disease with clinical symptoms related to the prominent involvement of cerebral cortex and basal ganglia. CBD is a pathological diagnosis and antemortem clinical diagnosis may change many times. In this paper, we described the clinical features and discussed a cases diagnosed with symmetric CBS because of its rarity. Case: Seventy-five-year-old woman presented with a three years history of difficulty in speaking and reading. Involuntary hand jerks and slowness of movement also had began in the last six months. In the neurological examination the patient was alert but not fully oriented. The speech was non-fluent, word finding difficulties were present. Bilateral limited upgaze, bradimimia, bilateral positive cogwheel' rigidity but prominent in the right side, postural tremor and negative myoclonus during action on the left side were detected. Receptive language was normal but expressive language and repetition were impaired. Acalculia, alexia, agraphia and apraxia were also present. CSF findings were unremarkable except for elevated protein level (75 mg/dL). MRI revealed bilateral symmetric cortical atrophy prominent in the frontoparietal region. PET showed hypometabolism in the left caudate nucleus. Conclusion: The increase of data related to neurodegenerative disorders associated with dementia, movement disorders and other findings results in an expanded range of diagnosis and transitions between clinical diagnosis. When considered the age of onset, clinical symptoms, imaging findings and prognosis of this patient, clinical diagnosis was CBS and pathologic diagnosis as probable CBD. Imaging of CBD usually consist of typical asymmetry between hemispheres. Still few cases with clinical appearance of CBD may show symmetrical cortical cerebral atrophy. It is presented this case who was diagnosed with CBD although we found symmetrical cortical cerebral atrophy in MRI.

Keywords: symmetric cortical atrophy, corticobasal degeneration, corticobasal syndrome

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Authors: Atmaja Patel

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Since the development of lasers in 1951, the first medical application was reported by Goldman in 1962. In 1960, T.H. Maiman produced the first Ruby laser and was used in cardiovascular surgery by McGuff in 1963. After a long time of investigations and new developments in laser technology first clinical applications were performed by Choy and Ginsburg in 1983. Introduction of the first true dental laser was in 1989. This paper is to highlight the various treatments and prevention of periodontal diseases. Lasers have become more predictable and effective form of treatment for periodontal diseases. The advantages of lasers include reduced use of anaesthesia, coagulation that yields a dry surgical field and hence better visibility, reduced need of sutures, minimal swelling and scarring, less pain and medication, faster healing and increased patient acceptance.

Keywords: lasers, periodontal surgery, diode laser, healing

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

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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

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Authors: Catherine Bernard, Paul Ransom

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Recent events have prompted emergency planners to re-evaluate their emergency response to major incidents and mass casualties. At the Royal Sussex County Hospital, we have adopted a tiered system comprised of three levels, anticipating an increasing P1, P2 or P3 load. This will aid planning in the golden period between Major Incident ‘Standby,’ and ‘Declared’. Each tier offers step-by-step instructions on appropriate patient movement within and out of the department, as well as suggestions for overflow areas and additional staffing levels. This system can be adapted to individual hospitals and provides concise instructions to be followed in a potentially overwhelming situation.

Keywords: disaster planning, emergency preparedness, major incident planning, mass casualty event

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Authors: Philippa Saunders, Claire Fletcher

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INTRODUCTION: Prostate cancer is the most prevalent malignancy affecting Western males. It is initially an androgen-dependent disease: androgens bind to the androgen receptor and drive the expression of genes that promote proliferation and evasion of apoptosis. Despite reduced androgen dependence in advanced prostate cancer, androgen receptor signaling remains a key driver of growth. Androgen deprivation therapy (ADT) is, therefore, a first-line treatment approach and works well initially, but resistance inevitably develops. Abiraterone and Enzalutamide are drugs widely used in ADT and are androgen synthesis and androgen receptor signaling inhibitors, respectively. The shortage of other treatment options means acquired resistance to these drugs is a major clinical problem. MicroRNAs (miRs) are important mediators of post-transcriptional gene regulation and show altered expression in cancer. Several have been linked to the development of resistance to ADT. Manipulation of such miRs may be a pathway to breakthrough treatments for advanced prostate cancer. This study aimed to validate ADT resistance-implicated miRs and their clinically relevant targets. MATERIAL AND METHOD: Small RNA-sequencing of Abiraterone- and Enzalutamide-resistant C42 prostate cancer cells identified subsets of miRs dysregulated as compared to parental cells. Real-Time Quantitative Reverse Transcription PCR (qRT-PCR) was used to validate altered expression of candidate ADT resistance-implicated miRs 195-5p, 497-5p and 29a-5p in ADT-resistant and -responsive prostate cancer cell lines, patient-derived xenografts (PDXs) and primary prostate cancer explants. RESULTS AND DISCUSSION: This study suggests a possible role for miR-497-5p in the development of ADT resistance in prostate cancer. MiR-497-5p expression was increased in ADT-resistant versus ADT-responsive prostate cancer cells. Importantly, miR-497-5p expression was also increased in Enzalutamide-treated, castrated (ADT-mimicking) PDXs versus intact PDXs. MiR-195-5p was also elevated in ADT-resistant versus -responsive prostate cancer cells, while there was a drop in miR-29a-5p expression. Candidate clinically relevant targets of miR-497-5p in prostate cancer were identified by mining AGO-PAR-CLIP-seq data sets and may include AVL9 and FZD6. CONCLUSION: In summary, this study identified microRNAs that are implicated in prostate cancer resistance to androgen deprivation therapy and could represent novel therapeutic targets for advanced disease.

Keywords: microRNA, androgen deprivation therapy, Enzalutamide, abiraterone, patient-derived xenograft

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Authors: Khaled Igbaria

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While Ba'albakī ceased writing or publishing since 1964, it is considerable and significant to investigate Ba'albakī's influence on others. This paper examines her influence on three Lebanese women writers: Emily Nasrallah, Muná Jabbūr, and Hanan al-Shaykh. However, the aim is not simply to examine the influence of the writer on these three authors, but rather to note similarities and differences in the challenges they faced and the agendas they followed in their fiction writing. For each of these writers, this article will describe elements of their literature, and then sketch out the influence which Ba'albakī has had on them. This paper relies on material from Sidawi because it includes interviews with the female writers discussed that are relevant to the current discussion. Sidawi asked them about Ba'albakī and her influence on them, the challenges they faced, and how they coped with them. This paper points out their comments using their own words. To be clear, examining these writers' notes and works is beyond the scope of this paper. To sum up, there are significant parallels between the life and work of Ba'albakī, and other Lebanese women writers such as Nasrallah, Jabbūr and al-Shaykh. Like Ba'albakī, Nasrallah and al-Shaykh also suffered in their struggle against their families. Nasrallah and al-Shaykh, like Ba'albakī, suffered because their society did not trust in their abilities and creativity. Ba'albakī opted for isolation because of her conflict with patriarchal society including the Lebanese women’s groups, while Nasrallah's isolation was because she preferred individualism and autonomy, and Jabbūr, as could be speculated, was not able to cope with the suffering caused by her role as a woman writer within Lebanese society. Whereas Ba'albakī isolated herself from the Lebanese women’s groups, focusing instead on her feminist writing and joining the Shi'r group, Al-Shaykh and the Lebanese women’s groups are able to cooperate in harmony. Furthermore, while Nasrallah and Al-Shaykh continued to publish fiction, Ba'albakī stopped publishing fiction in 1964. All of the above confirms not only that it is worthy to investigate deeply and academically both the biography and the works of Ba'albakī, but also that she deserves to include her throughout the top great Arab female writers, at the time, like Al-Shaykh and Nawal El Saadawi.

Keywords: feminist writing, Hanan Al-Shaykh, Laylá Ba'albakī, Lebanese women writers, Muná Jabbūr

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Authors: Mahfoudha Sid'Elemine

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The refugee resettlement process profoundly shapes the trajectories of individuals in their new host countries, exerting lasting effects on their long-term integration. Prevailing literature underscores the pivotal role of trust in facilitating successful refugee resettlement. However, this research challenges the notion of trust as universally paramount, contending that its significance is contingent upon variables such as the nature of resettlement programs and the diverse backgrounds and perspectives of refugees. Rather than advocating for a blanket approach to trust-building, this research contends that for certain resettlement programs, trust may prove counterproductive amidst resource constraints and tight service timelines. Moreover, trust may not uniformly emerge as a primary requisite for all refugees, presenting formidable challenges in its establishment. Focusing specifically on resettlement in the United States, this study illustrates how the temporal constraints of resettlement services, coupled with refugees' varied cultural experiences, can impede the cultivation of trust between aid workers and refugees. As an alternative paradigm, this research proposes an approach centered on fostering opportunities for reciprocal engagement, positioning refugees as active contributors within their newfound communities. Embracing reciprocity as the cornerstone of burgeoning relationships promises to fortify refugees' ties with the broader community, bolster their autonomy, and facilitate sustained integration over time. The research draws upon qualitative analyses of in-depth interviews conducted with a subset of resettled refugees, as well as aid workers and volunteers involved in refugee resettlement endeavors within Hampton Roads, Virginia, over the past decade. Through this nuanced examination, the study offers insights into the complexities of trust dynamics in refugee resettlement contexts and advocates for a paradigm shift towards reciprocal integration strategies.

Keywords: Resettlement programs, Trust dynamics, Reciprocity, Long-term integration

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Authors: Apoorva D. R.

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INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a severe, potentially fatal syndrome in which there is excessive immune activation. The disease is seen in children and people of all ages, but infants from birth to 18 months are most frequently affected. HLH is a sporadic or familial condition that can be triggered by various events that disturb immunological homeostasis. In cases with a genetic predisposition and sporadic occurrences, infection is a frequent trigger. Because of the rarity of this disease, the diverse clinical presentation, and the lack of specificity in the clinical and laboratory results, prompt treatment is essential, but the biggest obstacle to a favorable outcome is frequently a delay in identification. CASE REPORT: Here we report a case of a 6-month-old male infant who presented to the dermatology outpatient with disseminated skin lesions present over the face, abdomen, scalp, and bilateral upper and lower limbs for the past month. The lesions were insidious in onset, initially started over the abdomen, and gradually progressed to involve other body parts. The patient also had a history of fever which was moderate in grade, on and off in nature for 1 month. There were no significant complaints in the past, family, or drug history. There was no history of feeding difficulties in the baby. Parents gave a history of developmental milestones appropriate for age. Examination findings include multiple well-defined monomorphic erythematous papules with a central crater present over bilateral cheeks. Few lichenoid shiny papules present over bilateral arms, legs, and abdomen. Ultrasound of the abdomen and pelvis showed mild degree hepatosplenomegaly, intraabdominal lymphadenopathy, and bilateral inguinal lymphadenopathy. Routine blood investigations showed anemia and lymphopenia. Multiple X-rays of the skull, chest, and bilateral upper and lower limbs were done and were normal. Histopathology features were suggestive of non-Langerhans cell cutaneous histiocytosis. CONCLUSION: HLH is a fatal and rare disease. A high level of suspicion and an interdisciplinary approach among experienced clinicians, pathologists, and microbiologists to define the diagnosis and causative disease are key to diagnosing this case. Early detection and treatment can reduce patient morbidity and mortality.

Keywords: histiocytosis, non langerhans cell, case report, fatal, rare

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Authors: Kazuhiro Tateda, Elisa Gonzalez, Shuhei Ito, Kirstin Heinrich, Kevin Sweetland, Pingping Zhang, Catia Ferreira, Michael Pride, Jennifer Moisi, Sharon Gray, Bennett Lee, Fred Angulo

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Clostridium difficile (C. difficile) is the most common cause of antibiotic-associated diarrhea and infectious diarrhea in healthcare settings. Japan has an aging population; the elderly are at increased risk of hospitalization, antibiotic use, and C. difficile infection (CDI). Little is known about the population-based incidence and disease burden of CDI in Japan although limited hospital-based studies have reported a lower incidence than the United States. To understand CDI disease burden in Japan, CLOUD (Clostridium difficile Infection Burden of Disease in Adults in Japan) was developed. CLOUD will derive population-based incidence estimates of the number of CDI cases per 100,000 population per year in Ota-ku (population 723,341), one of the districts in Tokyo, Japan. CLOUD will include approximately 14 of the 28 Ota-ku hospitals including Toho University Hospital, which is a 1,000 bed tertiary care teaching hospital. During the 12-month patient enrollment period, which is scheduled to begin in November 2018, Ota-ku residents > 50 years of age who are hospitalized at a participating hospital with diarrhea ( > 3 unformed stools (Bristol Stool Chart 5-7) in 24 hours) will be actively ascertained, consented, and enrolled by study surveillance staff. A stool specimen will be collected from enrolled patients and tested at a local reference laboratory (LSI Medience, Tokyo) using QUIK CHEK COMPLETE® (Abbott Laboratories). which simultaneously tests specimens for the presence of glutamate dehydrogenase (GDH) and C. difficile toxins A and B. A frozen stool specimen will also be sent to the Pfizer Laboratory (Pearl River, United States) for analysis using a two-step diagnostic testing algorithm that is based on detection of C. difficile strains/spores harboring toxin B gene by PCR followed by detection of free toxins (A and B) using a proprietary cell cytotoxicity neutralization assay (CCNA) developed by Pfizer. Positive specimens will be anaerobically cultured, and C. difficile isolates will be characterized by ribotyping and whole genomic sequencing. CDI patients enrolled in CLOUD will be contacted weekly for 90 days following diarrhea onset to describe clinical outcomes including recurrence, reinfection, and mortality, and patient reported economic, clinical and humanistic outcomes (e.g., health-related quality of life, worsening of comorbidities, and patient and caregiver work absenteeism). Studies will also be undertaken to fully characterize the catchment area to enable population-based estimates. The 12-month active ascertainment of CDI cases among hospitalized Ota-ku residents with diarrhea in CLOUD, and the characterization of the Ota-ku catchment area, including estimation of the proportion of all hospitalizations of Ota-ku residents that occur in the CLOUD-participating hospitals, will yield CDI population-based incidence estimates, which can be stratified by age groups, risk groups, and source (hospital-acquired or community-acquired). These incidence estimates will be extrapolated, following age standardization using national census data, to yield CDI disease burden estimates for Japan. CLOUD also serves as a model for studies in other countries that can use the CLOUD protocol to estimate CDI disease burden.

Keywords: Clostridium difficile, disease burden, epidemiology, study protocol

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