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A model that takes into consideration radial and axial changes in velocity in a tubular reactor for the thermal polymerization of styrene is used to simulate the effect of changes in inlet tube wall temperature and tube radius. The reactor performance is sensitive to the changes of these parameters. The method of orthogonal collocation is used to discretize the modeling equation in the radial direction and Gear method to solve the resulting stiff differential equations in the axial direction. It is found that reducing the wall temperature and the tube radius along the direction of the flow of the monomer reduces the variation in conversion between the tube center and tube wall and thus are advantageous., INTRODUCTION Polystyrene is usually produced by free radical bulk polymerization of styrene in a batch tank reactor (expandable polystyrene) or continuous stirred tank reactor (general purpose and high impact polystyrene). [...]

Avascular necrosis (AVN) of the femoral head is a rare complication that can be associated with prolonged use of glucocorticoids. On reviewing the literature, this is the first case of bilateral AVN secondary to the long use of topical steroids in an eosinophilic esophagitis (EoE) patient. A 28-year-old man presented to our gastroenterology clinic for worsening fibrostenotic (EoE) despite being on swallowed fluticasone administered through an inhaler for seven years. The latter was stopped, and the patient was commenced on dupilumab. The patient was referred to orthopedics to manage his limping and groin pain. Bilateral hip replacements were performed when bilateral AVN was confirmed on MRI of both hips. The patient's EoE symptoms resolved after endoscopic dilation and an ongoing course of dupilumab. Furthermore, dupilumab showed an excellent control of the disease activity based on esophageal biopsies. To our knowledge, this is the first case report of such an entity. Our case highlights the need to promote awareness of such serious side effects of prolonged use of topical corticosteroids among healthcare providers, even if administered through a metered inhaler., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Alakrad et al.)

Myeloid sarcoma (MS) is a proliferation of immature myeloid cells that occurs extramedullary, often accompanying acute myeloid leukemia (AML). It typically presents in areas such as lymph nodes, skin, and the head and neck regions. The emergence of MS within the temporal bone is rare, and it can manifest through nonspecific symptoms. In this paper, we reported a case of A 47-year-old female presented with right-sided otalgia, otorrhea, tinnitus, reduced hearing, and ear fullness, and developed facial asymmetry. She was initially diagnosed with necrotizing otitis externa and was treated accordingly. Further investigations were conducted, leading to the diagnosis of MS. She began treatment with induction chemotherapy followed by consolidation therapy. And we reviewed the literature and included 14 MS cases with the same anatomical localization, discussing the primary presentation, immunohistochemistry, and treatment approaches of these patients. In conclusion, temporal bone MS should be considered in patients with a history of AML presenting with nonspecific symptoms. Diagnostic modalities for MS include computed tomography and magnetic resonance imaging scans. Systemic chemotherapy remains the preferred treatment approach. The complexity and diversity of temporal bone MS presentations necessitate further comprehensive research to enhance understanding and improve management strategies for this rare condition., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Malignant peripheral nerve sheath tumors (MPNSTs) are rare tumors that develop from peripheral nerve sheath cells and they account for approximately 5% to 10% of all soft-tissue sarcomas. MPNSTs in the head and neck region represent approximately 2% to 6% of all head and neck sarcomas and account for 12% to 19% of all MPNSTs, and the infratemporal fossa is a rare site for MPNSTs. MPNSTs originating from the trigeminal nerve are extremely rare. Case presentation: A 19-year-old female presented with a 6-month history of left-sided facial pain and paresthesia on the same side. On examination, there was left-sided facial paresthesia at the third trigeminal nerve (V3) areas; computed tomography scanning and magnetic resonance imaging showed an infratemporal lesion and surgical resection was done. Histological examination and the immunostaining finding showed high-grade MPNST. Conclusion: MPNSTs in the head and neck region may manifest with nonspecific symptoms. The diagnosis often requires a combination of clinical, pathological, and immunohistochemistry studies. Treatment involves total surgical resection with adjuvant radiotherapy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Reactive oxygen species (ROS) serve vital physiological functions, but aberrant ROS production contributes to numerous diseases. Unfortunately, therapeutic progress targeting pathogenic ROS has been hindered by the limited understanding of whether the mechanisms driving pathogenic ROS differ from those governing physiological ROS generation. To address this knowledge gap, we utilised a cellular model of Parkinson's disease (PD), as an exemplar of ROS-associated diseases. We exposed SH-SY5Y neuroblastoma cells to the PD-toxin, MPP + (1-methyl-4-phenylpyridinium) and studied ROS upregulation leading to cell death, the primary cause of PD. We demonstrate: (1) MPP + stimulates ROS production by raising cytoplasmic Ca 2+ levels, rather than acting directly on mitochondria. (2) To raise the Ca 2+ , MPP + co-stimulates NADPH oxidase-2 (NOX2) and the Transient Receptor Potential Melastatin2 (TRPM2) channel that form a positive feedback loop to support each other's function. (3) Ca 2+ exacerbates mitochondrial ROS (mtROS) production not directly, but via Zn 2+ . (4) Zn 2+ promotes electron escape from respiratory complexes, predominantly from complex III, to generate mtROS. These conclusions are drawn from data, wherein inhibition of TRPM2 and NOX2, chelation of Ca 2+ and Zn 2+ , and prevention of electron escape from complexes -all abolished the ability of MPP + to induce mtROS production and the associated cell death. Furthermore, calcium ionophore mimicked the effects of MPP + , while Zn 2+ ionophore replicated the effects of both MPP + and Ca 2+ . Thus, we unveil a previously unrecognized signalling circuit involving NOX2, TRPM2, Ca 2+ , Zn 2+ , and complex III that drives cytotoxic ROS production. This circuit lies dormant in healthy cells but is triggered by pathogenic insults and could therefore represent a safe therapeutic target for PD and other ROS-linked diseases., (© 2024. The Author(s).)

Key Clinical Message: Pauci-immune necrotizing glomerulonephritis (PING) is a small vessel renal vasculitis usually associated with the presence of antineutrophil cytoplasmic antibodies (ANCA) against myeloperoxidase or proteinase. A small proportion of PING patients do not have ANCA antibodies., Abstract: A condition known as Pauci-immune necrotizing glomerulonephritis, or PING for short, is a type of kidney inflammation that affects small blood vessels. This condition is typically linked with the existence of certain antibodies, specifically antineutrophil cytoplasmic antibodies or ANCA, which target myeloperoxidase or proteinase. However, it's worth noting that a minor percentage of individuals diagnosed with PING do not possess these ANCA antibodies. A 24-year-old woman with no previous medical history arrived at the ER due to various symptoms including joint pain, fever, difficulty swallowing, and shortness of breath. Despite multiple symptoms suggesting systemic lupus erythematosus (SLE), this diagnosis was ruled out based on the EULAR/ACR 2019 classification criteria and laboratory tests. Other potential diagnoses such as rheumatoid arthritis (RA) and eosinophilic garnulomatosis with polyaniitis (EGPA) were also excluded based on respective criteria. The patient was treated with a 3-day course of methylprednisolone, followed by prednisolone, which improved her creatinine levels. Subsequent tests for P-ANCA and C-ANCA were negative. A kidney biopsy confirmed necrotizing glomerulonephritis, consistent with pauci-immune vasculitis. A bronchoscopy revealed bleeding and hemorrhage in her lungs, but bacterial culture analysis was negative. The patient was given piperacillin, tazobactam, and vancomycin for septic coverage, as well as intravenous immunoglobulin (IVIg), which led to symptom improvement., (© 2024 The Author(s). Clinical Case Reports published by John Wiley & Sons Ltd.)

Background: Delirium is prevalent in elderly patients, linked to elevated mortality rates, heightened healthcare resource use, and caregiver burden. Inflammatory bowel disease (IBD) poses various delirium risk factors, yet the impact on geriatric IBD patient outcomes remains unexplored., Methods: Using 2016-2019 National Inpatient Sample data, we identified ≥65-year-old patients admitted for IBD (Crohn's, ulcerative colitis) management stratified by delirium presence as a secondary diagnosis. The study aimed to assess delirium's impact on geriatric IBD patient outcomes., Results: Among 67,534 elderly IBD admissions, 0.7% (470) developed delirium. The delirium group had a 4.8-fold increase in in-hospital mortality risk (odds ratio 4.80, P  < 0.001, 95% confidence interval [CI] 1.94-11.8). IBD patients with delirium experienced prolonged length of stay (adjusted mean difference 5.15 days, 95% CI 3.24-7.06, P  < 0.001) and increased care costs (adjusted mean difference $48,328, 95% CI $26,485-$70,171, P  < 0.001) compared to those without delirium., Conclusion: Elderly IBD patients with delirium face higher mortality risk, prolonged hospitalization, and increased healthcare costs. Clinicians should recognize delirium's detrimental effects in this vulnerable group and adhere to preventive protocols for improved care., Competing Interests: The authors report no funding or conflicts of interest., (Copyright © 2024 Baylor University Medical Center.)

Background Gastroparesis, characterized by delayed gastric emptying without mechanical obstruction, is a significant complication, especially in diabetic individuals. It manifests through symptoms such as abdominal bloating, feelings of fullness, and pain. This study investigates the prevalence of gastroparesis among non-diabetic and diabetic patients, exploring associations with demographic data, hemoglobin A1C (HbA1C) levels, and symptoms. Methodology This retrospective, observational, cohort study included patients with gastroparesis symptoms who underwent a nuclear gastric emptying study from January 2021 to April 2023. The study analyzed demographic data, symptoms, and HbA1c levels to identify correlations with delayed gastric emptying. Results Of 157 patients, 34.4% exhibited delayed gastric emptying. Diabetic patients comprised 29.3% of the sample, with a notable disease duration of over 10 years in 77.3% of cases. Symptoms such as nausea, vomiting, epigastric pain, and early satiety were prevalent, with significant associations between delayed emptying and female gender, higher HbA1c, and vomiting. Conclusions Delayed gastric emptying is significantly associated with female gender, elevated HbA1c levels, and when vomiting is the presenting symptom. Highlighting the importance of awareness among healthcare providers and the community, the findings encourage collaborative efforts for further gastroparesis research to better understand the predictive factors and mechanisms., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Shehata et al.)

Introduction: Acquired external auditory canal (EAC) atresia is a very rare condition, especially due to direct trauma. The challenge lies in the difficulty of treatment and the tendency to recur even after a long period. Here we present a case report of treatment of recurrent EAC atresia resulting from a dog bite using a silicone stent prosthesis., Case Presentation: A 4-year-old, bitten by a dog, suffered severe head injuries, including scalp avulsion and left auricle avulsion. Initial treatment included wound closure, antibiotics, and vaccines. However, complications arose, leading to left EAC atresia and hearing loss. Surgical interventions, including canaloplasty and skin grafting, were conducted, with recurrence prompting second surgery with using a silicon prosthetic post-surgery. Follow-up for up to 14 months showed no evidence of recurrence of atresia, with complete improvement in hearing., Discussion: Acquired stenosis of the External Auditory Canal (EAC) can result from various factors, predominantly otitis externa and traumatic incidents, including previous surgeries. Though direct trauma is rare, it can lead to stenosis. Surgical intervention is often necessary for post-traumatic cases, involving removal of obstructions, canal widening, and reconstruction. Management depends on maturity of stenosis, with non-surgical methods for soft stenoses and surgical procedures for mature ones, often supplemented by postoperative stents to preventing restenosis., Conclusion: Acquired external auditory canal atresia remains a rare, difficult-to-treat entity with a high rate of recurrence. The use of a silicone prosthesis stent after surgery can be considered an effective method in preventing recurrence., Competing Interests: Declaration of competing interest The Authors disclose no conflicts., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The profession of pharmacy has evolved significantly in recent years in terms of professional service delivery. The aim of this study was to explore the current views of pharmacists in the United Arab Emirates (UAE) on pharmaceutical care services and the nature of barriers encountered in practice using qualitative and quantitative assessment methods. Methods: A cross-sectional study was conducted among hospital and community pharmacists (n = 305) between March and May 2021, using qualitative and quantitative assessment methods. In the qualitative phase, 15 interviews were conducted to explore five main criteria: patient information, inadequate patient counseling, prescribing errors prevention and identifying drug-related problems, lack of participation in health awareness programs, and barriers to pharmaceutical care implementation. In the quantitative phase, 305 consenting pharmacists completed a questionnaire on seven criteria: demographic profile, pharmacist-physician interaction, patient counseling assessment, patient reports of adverse drug events, pharmacist participation in health awareness programs, perceptions of reducing prescribing errors and identifying drug-related problems, and barriers to appropriate pharmaceutical care implementation. Results: The results of both the qualitative and quantitative phases of the study revealed that pharmacists' influence on practice in the UAE is limited due to many factors, mainly lack of time and patients' ignorance of the pharmacist's role in the medical field. The mean responses regarding pharmacists' approach to patient counseling and patients' knowledge of pharmacists' role in managing adverse drug reactions were 77.1% and 59.7%, respectively. Active participation in health awareness programs was 64.8%. The mean positive response of participants in reducing prescribing errors and recognizing drug-related problems was 9.2%. Pharmacists' age and number of years in practice were the most important factors influencing the pharmaceutical care services implementation. Conclusion: The study has shown the need to shed light on the proper implementation of pharmaceutical care while maintaining a trusting relationship with physicians., Competing Interests: No competing interests were disclosed., (Copyright: © 2022 Kharaba Z et al.)

Thyroid storm (TS) is a rare but life-threatening complication of hyperthyroidism in which multiorgan failure (MOF) is the most common cause of death. Early diagnosis and treatment of TS are challenging. We presented two cases with refractory TS complicated with arrhythmia, cardiac arrest, cardiogenic shock and MOF and were not responding to medical treatment, therapeutic plasma exchange or continuous renal replacement therapy. The combination of extracorporeal membrane oxygenation (ECMO) and early thyroidectomy was the mainstay treatment that was performed with no complications. MOF was resolved and patients were doing well in the outpatient clinic follow-up. Precautions concerning the beta blockers and anti-thyroid medications use in TS, especially in the acute setting, should be considered. Upon its availability, the use of ECMO and early thyroidectomy is efficient. This is most applicable in patients not responding to medical treatment or patients who develop complications related to the TS and its medical treatment., (Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2022.)

Celiac disease (CD) is a chronic immune-mediated small-intestinal disorder. The tissue transglutaminase (TTG) antibodies test is the initial step in the diagnosis of CD. Intussusception is a process where one segment of the bowel invaginates into the lumen of an adjacent segment. Despite that, the association between adult intussusception and CD has been descried previously, and it is still not widely recognized. We report a case of adult intussusception as the first manifestation of CD. A 28-year-old nonalcoholic and nonsmoker, previously healthy man, presented to the emergency department with a 1-week history of progressive diffuse abdominal pain associated with abdominal distension, nausea, vomiting, diarrhea, and 7 kg weight loss. The physical exam was remarkable for thin body habitus with no lymphadenopathy. Laboratory testing was significant for hypochromic microcytic anemia, AST 214 IU/L, ALT 217 IU/L, alkaline phosphatase 183 IU/L, and INR 2.9. An abdominal radiograph showed distended gas-filled small- and large-bowel loops. An abdominal computed tomography scan with contrast was done and demonstrated a telescoping of the small bowel in at least 3 areas with a target sign appearance with no signs of obstruction that suggested small-bowel intussusception. Following this imaging result, the patient was admitted under general surgery and kept nothing by mouth. The surgical team approached the gastroenterology team for push enteroscopy with biopsy which the patient refused. Further investigation included TTG antibodies; IgA and IgG were significantly elevated, 4,965.5 CU and 431.9 CU, respectively (reference: <19.9 CU). The diagnosis of CD leading to adult intussusception was made. The patient was advised to start a gluten-free diet. During the hospital stay, the patient had complete resolution of his symptoms and was discharged home. In summary, this case highlights the potential link between adult intussusception and CD. Adult intussusception is a rare condition that its underlying etiology should be meticulously investigated to expedite treatment and prevent unnecessary surgical intervention., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 by S. Karger AG, Basel.)

Objectives: The inappropriate use of medications is harmful and is a common issue in hospitalised patients. Patients hospitalised in general surgery wards are usually at high risk for drug-related problems (DRPs). This randomised controlled trial aimed to explore the value of a pharmaceutical care service conducted in general surgery wards in the identification and reduction of DRPs in comparison with standard medical care., Methods: This study was conducted in general surgery wards including abdominal, cardiovascular, vascular, endocrine, orthopaedic and oncological surgeries at one of the largest teaching hospitals in Jordan over a period of 6 months. Recruited patients were randomised into intervention or control groups. Clinical pharmacists assessed patients' DRPs and submitted recommendations to resolve the identified DRPs in the intervention group., Results: Patients in the intervention group (n=63) and the control group (n=60) had a mean age of 55±14.4 years, with 52.0% being women. A total of 1062 DRPs were identified, with a mean of 8.6±3.6 per patient (intervention group, 8.65±4.2; control group, 8.62±2.6; p=0.56). The commonly identified DRPs included safety (20.2%) and efficacy (19.0%) issues. The acceptance rate for pharmacists' recommendations by physicians was very high (90%) with a good DRP correction rate of 58.9% during patients' hospital stay. The value of pharmaceutical care was significantly reflected in the achievement of the therapeutic outcomes and prevention of morbidity (resolved/improved or prevented) of 68.2% (24.2%+44%) in the intervention group compared with 19.2% (12.4%+6.8%) in the control group (p<0.001)., Conclusions: This study shows that DRPs are common among general surgery patients in Jordan, especially those related to drug safety and efficacy. Pharmacists' recommendations contributed substantially to resolving most of the identified DRPs and had a significant impact on improving medications used in general surgery patients., Competing Interests: Competing interests: None declared., (© European Association of Hospital Pharmacists 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study aims to compare the 2017-ACC/AHA hypertension guideline with 2014-JNC-8 guideline in regard to the number of patients who are eligible for treatment and to determine the physicians' adherence and the financial impact of implementing the new guideline., Methods: A cross-sectional observational study was conducted on adult patients who attended the hospital outpatient setting in UAE during January 1, 2018 till February 28, 2018. Adults who are diagnosed with hypertension and those with blood pressure (BP) levels based on two or more readings obtained on two or more different occasions were screened for inclusion into this study and cardiovascular diseases (CVD) risk was calculated. The two guidelines were compared with respect to the number of patients diagnosed with hypertension and eligible for treatment. Results were extrapolated to the UAE population. Financial impact of applying the 2017-ACC/AHA guideline was also evaluated., Results: In comparison with the JNC-8, the 2017-ACC/AHA guideline would increase the proportion of patients diagnosed with hypertension among UAE adults from 40.8% to 76.3% and the number of UAE adults recommended for antihypertensive medications would rise from 2.42 million (32.1%) to 4.71 million (62.5%). Among UAE adults, almost 4.42 million (58.6%) and 0.76 million (10.1%) would have BP above the target according to the 2017-ACC/AHA and JNC-8 guidelines, respectively. The expected increase in the cost of anti-hypertension medications prescribed for the new labeled cases according to 2017-ACC/AHA but not JNC-8 would reach 1.8 billion AED/year. For those who were recommended for antihypertensive medications, who had BP above target, the additional cost would reach 3.5 billion AED/year., Conclusions: The current study reveals marked increase in the proportion of patients diagnosed with hypertension in concordance with the 2017-ACC/AHA guideline. This is also will be associated with almost double the number of UAE adults recommended for antihypertensive medications. The poor compliance with the 2017-ACC/AHA reflects the concern regarding the increase risk of adverse events., Competing Interests: Conflict of interest We “Authors” declare that we have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 Saudi Heart Association.)

Wilson's disease (WD) is an autosomal recessive disease affecting the copper metabolism resulting in various clinical presentations. Diagnosis includes the presence of low serum copper and ceruloplasmin concentrations, increased urinary copper excretion, and/or increased hepatic copper concentrations. Yet, genetic testing remains diagnostic. Management includes copper chelating agents and liver transplant in advance cases. We report a case of WD presenting with liver function impairment in late adult life and started on treatment. Therefore, early diagnosis and treatment of WD can prevent related complications., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 by S. Karger AG, Basel.)

Background: A graduating medical doctor is expected to be competent in physical examinations across all systems. The exploration of how gender affects the development of clinical skills has not been explored in an Arab context, despite cultural restrictions that make it more difficult for students and doctors to examine the opposite sex., Methods: A cross sectional survey was undertaken of graduating final year medical students in Northern Jordan. We asked about students' perceptions regarding factors that may impact the development of clinical skills potentially related to gender, and asked about the frequency of examinations performed during their training for intimate and general physical examinations on all patients, as well as patients of the opposite sex. We also asked about the students' confidence in performing the examinations (3-point Likert-scale). Comparison of male and female proportions was done using Chi square tests analysis., Results: One hundred eighty-eight final year students from 481 students (41%) completed the survey, 99 males and 89 females. The greatest factor given for impacting a student's clinical examination of a patient of the opposite sex was cultural or religious traditions. Overall male students perform more clinical examinations than female students, with the odds of a male conducting more than 10 cardiovascular examinations on any patient compared to female students being 2.07 (1.13-3.79) and as high as 3.06 (1.53-6.18) for thyroid examinations. However, females were significantly more likely to examine male patients than vice versa (0.49 (0.27-0.88) for cardiovascular and 0.39 (0.21-0.71) for respiratory examinations). The gender division was more prominent for intimate examinations, with a lower odds of males conducting breast 0.11 (0.04-0.28) and vaginal examinations 0.22 (0.02-1.98) and more male students conducting prostate examinations OR 11.00 (1.39-87.03) and male genitalia examinations OR 16.31 (3.75-70.94). Overall a large proportion of students had never performed common intimate clinical examinations at all., Conclusions: In our context, clinical exposure to both intimate and general clinical examinations differs significantly between male and female students. A greater awareness and more research on the influence of gender on clinical skill attainment in conservative cultures is needed with appropriate adaption of clinical teaching., Trial Registration: Non interventional thus not required.