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Abstract Background The economic crisis in Sri Lanka worsened food insecurity, with millions facing moderate-to-severe food shortages. This study evaluates the effectiveness of cash transfers combined with mobile health education in enhancing dietary diversity and food security among Sri Lankan households during the crisis. Methods This quasi-experimental single-group pre-post study involved 1040 eligible individuals selected through stratified random sampling from eligible households of Samurdhi beneficiaries and smallholder farmers. The intervention included a cash transfer of LKR 22,500 and weekly nutrition awareness messages via WhatsApp and SMS complemented by a one-time awareness session. Dietary diversity and food security were assessed using standard validated tools such as the Diet Quality Questionnaire and Food Security Questionnaire. Results Food insecurity decreased significantly from 89.3% (n = 681) in the pre-test to 76.9% (n = 533) in the post-test, with a 12.4% reduction (95% CI, 8.57 to 16.24, p

Deep venous thrombosis is a common and potentially life-threatening condition that is often associated with various risk factors including underlying malignancy. In this case report, we present a male patient who presented with deep venous thrombosis as the earliest presenting feature of metastatic gallbladder carcinoma. This case report emphasizes the importance of thorough evaluation of patients presenting with unprovoked deep venous thrombosis to early detection of underlying malignancy.

Diagnosing neoplastic fever requires excluding identifiable causes, making it a diagnostic challenge. Fever as a primary manifestation of pancreatic adenocarcinoma is uncommon with few cases reported in the literature. Here we present an unusual case of metastatic pancreatic adenocarcinoma primarily manifesting as pyrexia of unknown origin. A 63-year-old Sri Lankan male, a non-smoker who was diagnosed with diabetes, hypertension and dyslipidaemia presented with a history of fever, anorexia and weight loss for 2 months. Despite the completion of treatment for positive serology for paratyphi, his symptoms and inflammatory markers remained elevated while the rest of the infectious screening was negative. On further evaluation, the patient was found to have a hypodense distal pancreas with ring-enhancing multiple liver lesions on imaging. Histology confirmed pancreatic adenocarcinoma with liver metastasis. Atypical liver metastases may present with evidence of ring enhancement in computed tomography imaging; thus, the biopsy is mandatory for diagnosis and decision-making. Usually, tumours of the pancreatic tail are resectable but if they are associated with liver metastatic disease, surgical resection is not recommended because it is not potentially curative. Therefore, in the context of metastatic pancreatic adenocarcinoma, palliative chemotherapy and pharmacological management of fever are required.

We present a case of primary angiosarcoma, an exceedingly rare malignant breast lesion, in a 21-year-old female patient with unilateral breast enlargement. Primary angiosarcoma is an aggressive form of breast cancer with variable presentation and limited clinical experience due to the rarity of the disease. Despite an initial diagnostic challenge, this report showcases the importance of a systematic diagnostic approach and multidisciplinary management in the context of uncommon breast lesions in young patients. Our patient underwent a mastectomy followed by breast reconstruction, achieving favourable cosmetic outcomes. This case serves as a contribution to our understanding of the diagnostic considerations surrounding angiosarcoma of the breast in a young patient.

Clinical fetal monitoring devices can only be operated by medical professionals and are overly costly, prone to detrimental false positives, and emit radiation. Thus, highly accurate, easily accessible, simplified, and cost-effective fetal monitoring devices have gained an enormous interest in obstetrics. In this study, a cost-effective and user-friendly wearable home fetal movement and distress detection device is developed and assessed for early-stage design progression by facilitating continuous, comfortable, and non-invasive monitoring of the fetus during the final trimester. The functionality of the developed prototype is mainly based on a microcontroller, a single accelerometer, and a specialized fetal phonocardiography (fPCG) acquisition board with a low-cost microphone. The developed system is capable of identifying fetal movement and monitors fetal heart rhythm owing to its considerable sensitivity. Further, the device includes a Global System for Mobile Communication (GSM)-based alert system for instant distress notifications to the mother, proxy, and emergency services. By incorporating digital signal processing, the system achieves zero false negatives in detecting fetal movements, which was validated against an open-source database. The acquired results clearly substantiated the efficacy of the fPCG acquisition board and alarm system, ensuring the prompt identification of fetal distress.

In patients with breast cancer, oncoplastic breast-conserving surgery can achieve a good aesthetic outcome without compromising oncological outcomes. However, tumors located in the upper inner quadrant (UIQ) are challenging for surgeons because treatment gives rise to visible scars, glandular deformities, and deviation of the nipple–areolar complex. The present study was performed to analyze a modification of the matrix rotation technique for UIQ tumors and address the main drawback of this technique, which is a visible scar on the commonly exposed part of the breast. A prospective database of seven patients who presented with UIQ tumors and underwent the new modification technique was utilized for the analysis. All patients preferred the modified technique over the standard technique because of the absence of a scar in the UIQ (visible breast line). The postoperative patient-reported outcomes regarding breast shape, breast symmetry, and scar location were also satisfactory. No surgical complications were reported. This modified surgical technique results in a scarless UIQ and is an aesthetically acceptable procedure that can be considered for UIQ tumors.

Abstract Background Hearing loss is the third leading global cause of disability and is associated with poorer quality of life. Hearing aids are often recommended for hearing loss; however, hearing aid uptake and use rates are perpetually low. Motivational interviewing (MI) is a patient-centered counseling aimed at addressing the desire in the patient to change their behavior. The aim of this study is to investigate the impact of one-on-one MI sessions on hearing aid use among new adult users. Methods A multi-center, prospective, randomized patient-blind controlled trial with a pre- and post-tests design. New hearing aid users ≥ 18 years of age will be recruited from Vancouver, Canada. They will be randomly assigned to a treatment or control group. The treatment group will attend a one-on-one MI session hosted by a practicing MI therapist in addition to standard in-person audiological care. The control group will receive standard in-person audiological care. Data is collected at baseline and at 1, 3, 6, and 12 months’ follow-ups. The primary outcomes are data-logged hearing aid use hours and patient-reported outcomes as measured by the International Outcome Inventory for Hearing Aids questionnaire. Associations between intervention and hearing aid use hours and self-reported outcome measures will be assessed. Discussion This trial is designed to evaluate the efficacy of one-on-one MI in improving hearing aid use in new adult users in the short and long terms. Results will contribute to the evidence on whether MI counseling has an effect on hearing aid use and may guide future clinical practices. Trial registration ClinicalTrials.gov NCT04673565 . Registered on 17 December 2020.

Gardasil 4, a human papilloma virus vaccine, has been shown to protect against various cancers, including cervical cancer. Common side effects include injection site pain, fever, headaches, and muscle aches. In some individuals, the severe side effect of postural orthostatic tachycardia syndrome (POTS) has been reported. POTS is characterized by the abnormal response of lightheadedness, blurry vision, and dizziness while transitioning to an upright posture. POTS predominately affects women, with more than eighty-five (85) percent of POTS patients being female. POTS, on average, takes five years and eleven months to receive diagnosis. Additionally, a strong association between POTS and Ehlers–Danlos Syndrome Type III (EDS) exists. Eighty (80) percent of patients with EDS have POTS. This severe side effect indicates that providers need to be aware of this strong association of HPV vaccinations and POTS. In this report, we will present a case of a young women with a past medical history significant for EDS type III who was diagnosed with POTS after receiving Gardasil 4 vaccination. This case demonstrates the need for physicians to be aware of the association of POTS with EDS type III and HPV vaccination. Physician awareness of the associations, signs, and symptoms of POTS and earlier testing at the first presentation of signs and symptoms will limit the negative impact on patient’s quality of life.

Splenic volvulus of wandering spleen is a rare clinical condition. It causes significant morbidity and mortality, especially if undetected. Here, we report a case of 32-year-old female who presented with worsening abdominal pain for 1-week duration. Contrast-enhanced computed tomography scan of the abdomen showed splenic volvulus with infarction and involvement of the pancreatic tail. She underwent exploratory laparotomy and splenectomy with preservation of the pancreatic tail. Patient progressed favourably. Our case report describes a rare clinical entity of a splenic volvulus with a twisted pancreatic tail. This is a life-threatening condition that requires prompt diagnosis and treatment.

Abstract Background Osteoarthritis (OA), a multifaceted condition, poses a significant challenge for the successful clinical development of therapeutics due to heterogeneity. However, classifying molecular endotypes of OA pathogenesis could provide invaluable phenotype‐directed routes for stratifying subgroups of patients for targeted therapeutics, leading to greater chances of success in trials. This study establishes endotypes in OA soft joint tissue driven by obesity in both load‐bearing and non‐load bearing joints. Methods Hand, hip, knee and foot joint synovial tissue was obtained from OA patients (n = 32) classified as obese (BMI > 30) or normal weight (BMI 18.5–24.9). Isolated fibroblasts (OA SF) were assayed by Olink proteomic panel, seahorse metabolic flux assay, Illumina's NextSeq 500 bulk and Chromium 10X single cell RNA‐sequencing, validated by Luminex and immunofluorescence. Results Targeted proteomic, metabolic and transcriptomic analysis found the inflammatory landscape of OA SFs are independently impacted by obesity, joint loading and anatomical site with significant heterogeneity between obese and normal weight patients, confirmed by bulk RNAseq. Further investigation by single cell RNAseq identified four functional molecular endotypes including obesity specific subsets defined by an inflammatory endotype related to immune cell regulation, fibroblast activation and inflammatory signaling, with up‐regulated CXCL12, CFD and CHI3L1 expression. Luminex confirmed elevated chitase3‐like‐1(229.5 vs. 49.5 ng/ml, p

Abstract Background Decreased pulmonary function and poor deglutition are a major risk factor for poststroke aspiration pneumonia. We analyzed the benefits of pulmonary training on pulmonary function, deglutition, and quality of life (QOL) in community‐dwelling, frail elderly people with chronic stroke. Method This study was designed as an open, randomized, controlled pilot trial. The participants, who were frail older adults with a history of stroke, were randomized to 2 rehabilitation groups: intervention group (n = 15) and control (n = 15). All participants (65–94 years) attended twelve 20‐min sessions twice a week for 6 weeks of either standard rehabilitation (control group) or standard rehabilitation with pulmonary training including home pulmonary exercise (intervention group). The main outcome measures were pulmonary function (%MIP), deglutition (DRACE), and QOL (SF8･PCS), while secondary outcomes were muscle strength (grip and abdominal), thorax flexibility, 6‐min walk distance, and activities in daily living. All outcomes were measured both prior to training and after the 12 sessions. Results The intervention group showed significant improvement in %MIP (95% CI, 2.9–31.6; p

Abstract The use of external fixators (EFs) dates back to 377 BC Hippocrates’ time, and it has a wide range of orthopaedic applications. External fixator has expanded its use in the management of fractures and other musculoskeletal conditions. It is widely used all over the world to manage complex musculoskeletal injuries. It has many advantages as compared to internal fixation in some trauma scenarios. However, the cost of the external fixators presents a dilemma to the healthcare system in developing countries. The goals of this review article are to explain the importance of EFs in developing countries in managing fractures, to determine the problems encountered at present during external fixation by developing countries, to identify solutions that could be used to address these issues, expand the use of external fixation into other domains of treatment, the impact of COVID-19 pandemic on fracture management based on existing literature. In conclusion, EFs are very expensive, researches have been conducted to overcome these barriers in developing countries. However, there are limitations in implementing in developing countries. It is important to have affordable and clinically acceptable EFs available in developing countries.

Abstract Background Current literature suggests the number of HIV clinicians in the United States is diminishing. There are 294,834 primary care providers (PCP) in the United States, and, of these, 3101 provide care to HIV-positive patients. More PCPs to treat and manage HIV patients may be the solution to alleviate the HIV provider shortage. However, PCPs also face challenges, including workforce shortages. We surveyed PCPs to determine perceived barriers, beliefs, and attitudes about their readiness to manage and treat HIV patients. Methods Following a quantitative, descriptive, cross-sectional survey design, currently practicing clinicians in primary care (physicians, residents, physician assistants, family nurse practitioners) were emailed a link to the study survey. Three hundred forty-seven family medicine clinicians from 47 states met the study inclusion criteria. Results Most (245/347, 70.6%) of the PCPs agreed that PCPs should take care of HIV patients. PCPs practicing HIV medicine (n = 171) were more likely than those not practicing HIV medicine (n = 176) to agree that PCPs should help with the HIV provider shortage (U = 10,384, p

Background: Synovial inflammation is associated with pain severity in patients with knee osteoarthritis (OA). The aim here was to determine in a population with knee OA, whether synovial tissue from areas associated with pain exhibited different synovial fibroblast subsets, compared to synovial tissue from sites not associated with pain. A further aim was to compare differences between early and end-stage disease synovial fibroblast subsets. Methods: Patients with early knee OA (n = 29) and end-stage knee OA (n = 22) were recruited. Patient reported pain was recorded by questionnaire and using an anatomical knee pain map. Proton density fat suppressed MRI axial and sagittal sequences were analysed and scored for synovitis. Synovial tissue was obtained from the medial and lateral parapatellar and suprapatellar sites. Fibroblast single cell RNA sequencing was performed using Chromium 10X and analysed using Seurat. Transcriptomes were functionally characterised using Ingenuity Pathway Analysis and the effect of fibroblast secretome on neuronal growth assessed using rat DRGN. Findings: Parapatellar synovitis was significantly associated with the pattern of patient-reported pain in knee OA patients. Synovial tissue from sites of patient-reported pain exhibited a differential transcriptomic phenotype, with distinct synovial fibroblast subsets in early OA and end-stage OA. Functional pathway analysis revealed that synovial tissue and fibroblast subsets from painful sites promoted fibrosis, inflammation and the growth and activity of neurons. The secretome of fibroblasts from early OA painful sites induced greater survival and neurite outgrowth in dissociated adult rodent dorsal root ganglion neurons. Interpretation: Sites of patient-reported pain in knee OA exhibit a different synovial tissue phenotype and distinct synovial fibroblast subsets. Further interrogation of these fibroblast pathotypes will increase our understanding of the role of synovitis in OA joint pain and provide a rationale for the therapeutic targeting of fibroblast subsets to alleviate pain in patients. Funding: This study was funded by Versus Arthritis, UK (21530; 21812)

Many hospitals face a common challenge: limited space for a high number of patients. This has led to quick patient throughput, which can impact patient perception of discharge readiness. This study examined whether a poster highlighting tasks to complete as part of the discharge process improved caregiver perception of readiness to transition home. Using a sequential, exploratory mixed methods design, focus groups were convened to explore clinical staff perspective on the discharge process on 3 pediatric inpatient units at a large, urban, pediatric academic medical center in the United States. Analysis of this content informed the design of a poster intervention to “nudge” caregivers (eg, parents, legal guardians) toward readiness and self-efficacy that was then tested in a randomized, controlled experiment. The poster focused on practical knowledge for specific areas of transition adjustment, such as medication and care recipient recovery behaviors, barriers, and enablers. Caregivers (n = 135) completed surveys at discharge indicating their perceived readiness to transition home with their child. Analysis of covariance was used to test the effect of the poster condition (poster vs no poster) on caregiver readiness, preparedness, and confidence for discharge while controlling for previous admission history. Significant effects for poster presence were found on caregivers’ perceived readiness for discharge, F 1,125 = 7.75, P = .006, Cohen’s d = 0.44; and caregivers’ perceived preparedness for the transition home, F 1,121 =7.24, P = .008, Cohen’s d = 0.44. Only a marginal effect was found for poster condition on caregivers’ confidence ratings, F 1,125 = 2.93, P = .090, Cohen’s d = 0.29. The results suggest that simple nudges in the patient care environment may yield measurable improvements in caregiver outcomes.

Abstract Background Hysterectomy is the commonest major gynaecological surgery. Although there are many approaches to hysterectomy, which depend on clinical criteria, certain patients may be eligible to be operated in any of the several available approaches. However, most comparative studies on hysterectomy are between two approaches. There is also a relative absence of data on long-term outcomes on quality of life and pelvic organ function. There is no single study which has considered quality of life, pelvic organ function and cost-effectiveness for the three main types of hysterectomy. Therefore, the objective of this study is to provide evidence on the optimal route of hysterectomy in terms of cost-effectiveness by way of a three-armed randomized control study between non-descent vaginal hysterectomy, total laparoscopic hysterectomy and total abdominal hysterectomy. Methods A multicentre three-armed randomized control trial is being conducted at the professorial gynaecology unit of the North Colombo Teaching Hospital, Ragama, Sri Lanka and gynaecology unit of the District General Hospital, Mannar, Sri Lanka. The study population is women needing hysterectomy for non-malignant uterine causes. Patients with a uterus > 14 weeks, previous pelvic surgery, those requiring incontinence surgery or pelvic floor surgery, any medical illness which caution/contraindicate laparoscopic surgery and who cannot read and write will be excluded. The main exposure variable is non-descent vaginal hysterectomy and total laparoscopic hysterectomy. The control group will be patients undergoing total abdominal hysterectomy. The primary outcome is time to recover following surgery, which is the earliest time to resume all of the usual activities done prior to surgery. In total, 147 patients (49 per arm) are needed to have 80% power at α-0.01 considering a loss to follow-up of 20% to detect a 7-day difference between the three routes; TLH versus TAH versus NDVH. The economic evaluation will take a societal perspective and will include direct costs in relation to allocation of healthcare resources and indirect costs which are borne by the patient. A micro-costing approach will be adopted to calculate direct costs from the time of presentation to the gynaecology clinic up to 6 months after surgery. Incremental cost-effectiveness ratios (ICER) will be obtained by calculating the incremental costs divided by the incremental effects (time to recover and QALYs gained) for the intervention groups (NDVH and TLH) over the standard care (TAH) group. Discussion The cost of the procedure, quality of life and pelvic organ function following the three main routes of hysterectomy are important to clinicians and healthcare providers, both in developed and developing countries. Trial registration The study was registered in the Sri Lanka clinical trials registry (SLCTR/2016/020) and the International Clinical Trials Registry Platform ( U1111-1194-8422 ) on 26 July 2016.

Abstract This tutorial serves as an introduction to normal radiographic anatomy of the extremities and back for preclinical students enrolled in medical human structure. It is composed of high-quality radiographs containing comprehensive labeling of bony structures. Image resolution exceeds that found in many more conventional learning resources such as textbooks, dissectors, and atlases. Images were digitized to stimulate self-directed study by integrating introductory radiographic anatomy into a structured format that is readily accessible for local and distance learning. Active learning was achieved by creating three tutorial units that provide learners with opportunities for repetition and self-assessment through immediate feedback and quizzes on labeled structures. The tutorial is best used in conjunction with radiology/anatomy lectures and labs to reinforce the didactic and practical experiences for learners enrolled in human anatomy courses. Organizing content into discrete tutorials is highly effective in teaching learners a large volume of information without overwhelming them all at once. Framing content in a clinically relevant manner not only serves to solidify what students have learned in their courses but also creates confidence by demonstrating how they will approach patient problems in their clinical years. This resource is completely self-contained and assigned for self-directed learning during the weeks when content is taught to preclinical students in human structure.

Abstract This tutorial serves as an introduction to normal cross-sectional anatomy of the abdomen and pelvis for preclinical students enrolled in medical human structure. This resource stimulates self-directed learning by integrating introductory radiographic anatomy into a structured format that is readily accessible for local and distance learning. Active learning was achieved by creating four tutorial units that target content areas dealing with computerized tomography (CT) scans of cross-sectional anatomy. Each unit provides opportunities for learner self-assessment through repetition and immediate feedback. This resource is best used in conjunction with radiology/anatomy lectures and labs to reinforce the didactic and practical (dissection) experiences for learners enrolled in human structure courses. In both 2007 and 2008, learners scored at the 77th percentile on the gross anatomy subject examination. These scores are significantly higher than those recorded prior to implementation of instructional technology in the curriculum beginning in 2001. Organizing content into discrete tutorials is highly effective in teaching learners a large volume of information without overwhelming them all at once. Exposing preclinical students to introductory CT scans of the abdomen and pelvis provides learners with a glimpse into the comprehensive evaluation of more contemporary imaging techniques such as magnetic resonance imaging (MRI) and positron emission tomography (PET) scans. Framing content in a clinically relevant manner not only serves to solidify what students have learned in their courses but also creates confidence by demonstrating how they will approach patient problems in their clinical years. These qualitative observations are supported by recent improvements in learner performance on National Board of Medical Examiners subject shelf exams.

Abstract This web-based tutorial serves as an introduction to sectional anatomy of the human brain for preclinical students enrolled in medical neurobiology or neuroanatomy. It was developed to stimulate self-directed local and distance learning by integrating sectional anatomy into a structured format that is readily accessible for identification of labeled structures in high-quality images of the normal brain. The knowledge gained is fundamental to the interpretation of CT, MRI, and PET-scans. Sections with Weil-Weigart stain were scanned, digitized, and converted into Adobe Authorware to provide learners with images of internal brain structures. Brain slices were grouped into four units that target content in coronal, oblique, horizontal, and sagittal planes of section. The tutorial complements didactic and practical activities of beginner healthcare professionals in their basic science years of study. Assignment of this tutorial for self-directed learning has freed up class time. Now students spend scheduled class time in active dissection or in integrating the lecture and laboratory course contents. This approach also addresses the paucity of qualified teaching faculty in the dissection laboratory, as the self-directed tutorial is peer-reviewed and accurate. Organizing content into a discrete tutorial has proven highly effective in teaching learners a large volume of information without overwhelming them all at once. It provides learners with a glimpse into the comprehensive evaluation of more contemporary brain imaging techniques like CT, MRI, and PET-scans. Framing content in a clinically-relevant manner not only serves to solidify what students learn in their anatomy courses, but also creates confidence by demonstrating how they will approach imaging of patient problems in their clinical years. Organizing content into discrete tutorials is highly effective in teaching learners a large volume of information without overwhelming them all at once. Preclinical students have the luxury of studying in the library, at home, or in the dissection laboratory and other study areas. A significant part of laboratory practical is identifying internal brain structures and learner performance has historically been poor on this portion of examinations. Exposing students to introductory sectional anatomy also provides learners with a glimpse into the comprehensive evaluation of more contemporary brain imaging techniques like CT, MRI, and PET-scans.

Abstract This interactive tutorial serves as an introduction to normal X-rays and cross sections of the abdomen and pelvis for preclinical students enrolled in medical and dental human structure. The course work was digitized and converted into an electronic format to provide beginners with introductory imaging critical to the interpretation of standard X-rays, computerized tomography (CT), and magnetic resonance imaging (MRI) scans. Its objective is to stimulate active self-directed learning by integrating introductory radiographic anatomy into a structured format that is readily accessible for local and distance learning. Active learning was achieved by creating six radiology tutorial units that target content areas dealing with standard and cross-sectional radiographic anatomy and arterial angiography. The tutorial complements didactic and practical (dissection) activities of beginner health care professionals enrolled in human structure. Both in 2007 and 2008, learners scored at the 77th percentile on the gross anatomy subject examination. These scores are significantly higher than those recorded prior to implementation of this instructional content in the curriculum beginning in 2001. Exposing preclinical students to introductory X-rays and cross sections of the abdomen and pelvis provided the learners with a glimpse into the comprehensive evaluation of more contemporary imaging techniques such as CT, MRI, and positron emission tomography (PET) scans. These qualitative observations are supported by recent improvements in learner performance on National Board of Medical Examiners subject shelf exams.

Abstract This interactive tutorial serves as an introduction to normal X-rays and cross sections of the thorax for preclinical students enrolled in medical and dental human structure. The courseware was digitized and converted into an online format to provide beginners with introductory imaging that is critical to the interpretation of standard X-rays, computerized tomography (CT), and magnetic resonance imaging (MRI) scans. Its objective is to stimulate active self-directed learning by integrating introductory radiographic anatomy into a structured format that is readily accessible for local and distance learning. It provides opportunities for learner self-assessment through repetition and immediate feedback and complements didactic and practical (dissection) activities of beginner health care professionals enrolled in human structure. In both 2007 and 2008, learners scored at the 77th percentile on the National Board of Medical Examiner's gross anatomy subject examination. These scores are significantly higher than those recorded prior to implementation of this instructional content in the curriculum beginning in 2001. Organizing content into discrete tutorials is highly effective in teaching learners a large volume of information without overwhelming them all at once. Exposing preclinical students to introductory X-rays and cross sections of the thorax provides learners with a glimpse into the comprehensive evaluation of more contemporary imaging techniques. Framing content in a clinically relevant manner not only serves to solidify what students have learned in their courses but also creates confidence by demonstrating how they will approach patient problems in their clinical years.